Swallowing Difficulties Diagnosis

  • Diagnosis

    The medical term for swallowing difficulties is dysphagia Figure 01. Swallowing requires normal function and coordination of the brain, nerves, muscles, teeth, and salivary glands. The swallowing process begins in the mouth and ends when food or liquids arrive in the stomach; dysphagia may result from conditions that affect at any point along this path.

    Click to enlarge: Anatomy of the digestive system

    Figure 01. Anatomy of the digestive system

    Dysphagia is a common symptom in the general population, but dysphagia is most common among older adults. Although anyone can experience dysphagia, the condition is most common in older adults. Up to 40% of nursing home residents are affected by the condition.

    All cases of dysphagia warrant medical attention. Dysphagia always requires medical attention, even if the symptoms are mild. Dysphagia can be an early warning symptom of a serious underlying condition. Furthermore, untreated swallowing disorders can lead to complications, including weight loss, malnutrition, dehydration, choking, a type of pneumonia caused by inhalation of food liquid, gases, dust, or fungi (aspiration pneumonia), and even death.

    The diagnosis and treatment of dysphagia usually involves a team of health care professionals. Several different types of doctors may help evaluate and treat dysphagia, including a primary care doctor, an otolaryngologist who is an ear, nose, and throat (ENT) doctor, a radiologist, a doctor who specializes in digestive conditions (gastroenterologist), and a rehabilitation specialist. The team usually also includes other health care professionals with specific expertise, such as speech-language pathologists, swallowing therapists, physical or occupational therapists, and dietitians.

    Because dysphagia can be caused by numerous underlying conditions, the treatment is tailored to the specific cause of dysphagia. Treatment may include drug therapy, swallowing rehabilitation, surgery, or some combination of these measures.

    There are two broad types of swallowing difficulties: one type affects the mouth and upper throat (oropharyngeal dysphagia), and the other type affects the esophagus (esophageal dysphagia) Figure 01. Oropharyngeal dysphagia refers to swallowing difficulties that affect the mouth and/or the upper throat (pharynx). In contrast, esophageal dysphagia refers to swallowing difficulties that affect the tube (esophagus) that connects the pharynx to the stomach. These two types of dysphagia can usually be distinguished based on a person's medical history (specific symptoms), the specific signs noted during a physical examination, and the results of diagnostic tests.

    There are many causes of both oropharyngeal dysphagia and esophageal dysphagia Table 01. Dysphagia is actually a symptom of an underlying condition. Because swallowing requires the healthy function of many different oral structures, muscles, and nerves, a wide range of different medical and dental conditions can cause dysphagia. Overall, oropharyngeal dysphagia is more common than esophageal dysphagia.

    Table 1.  Common Causes of Dysphagia

    Oropharyngeal dysphagia
    Stroke
    Parkinson?s disease
    Muscular dystrophy
    Tumors of the mouth or pharynx
    Drug-induced dry mouth (xerostomia)
    Radiation-induced dry mouth (xerostomia)
    Chemotherapy-induced inflammation of the mucosa of the mouth, ranging from redness to severe ulceration (mucositis).
    Esophageal dysphagia
    Inability to produce involuntary, wave-like contractions of esophagus (peristalsis), a condition know as achalasia?
    Esophageal spasms that block food and liquid instead of propelling them downward toward stomach (diffuse esophageal spasms)?
    Scleroderma: an autoimmune disease that can cause the weakening of tissues in the esophagus
    Age-related changes of motor function of esophagus
    Tumors of the esophagus
    Regions of narrowing (strictures)
    Lower esophageal ring that causes narrowing (Schatzki's ring)
    Pill-induced inflammation of the esophagus (pill esophagitis)?
    Esophagitis induced by gastroesophageal reflux disease (GERD)
    Functional (psychogenic) dysphagia: difficulty swallowing when no physical abnormalities are present; can be caused by stress

    Stroke is the most common cause of oropharyngeal dysphagia. Dysphagia can result from strokes that affect the area of the brain that controls motor actions (the cortex), and from strokes that affect the area of the brain that houses the swallowing center (the brain stem). About half of all stroke victims experience some degree of dysphagia in the post-stroke period, but in most of these cases, normal or near-normal swallowing function returns within one week.

    Esophageal dysphagia is most often due to actual blockages within the esophagus that are referred to as structural disorders. The disorders mechanically block food and liquid from moving towards the stomach. The most common structural problems are esophageal cancer, strictures, and lower esophageal rings (Schatzki's rings).

    • Esophageal cancer may cause dysphagia by narrowing the esophagus. This cancer most commonly occurs in older adults, and is often associated with rapid weight loss.
    • Strictures (narrowing of the esophagus) can be caused by any condition that causes severe acute injury, or chronic irritation of the esophageal lining. Gastroesophageal reflux disease (GERD) can lead to strictures; this condition is characterized by reflux of acidic stomach contents into the esophagus.
    • Schatzki’s rings (lower esophageal rings) are constrictive bands of connective tissue that occur in the inner wall of the lower esophagus. They are often associated with chronic reflux of the stomach contents. These rings usually don't produce symptoms unless they markedly narrow the esophagus.

    The conditions like achalasia or scleroderma can impair the normal, wave-like contractions of the esophagus (peristalsis) that propel food toward the stomach. Spasms of the esophagus can also interfere with peristalsis.

    • Achalasia is a disorder characterized by poor relaxation of the lower esophageal sphincter (LES) and loss of contractions of the esophageal muscle. As a result, food and liquids accumulate in the dilated esophagus.
    • Scleroderma is an autoimmune condition that can affect most organs and tissues of the body. Scleroderma can cause wasting of the esophageal muscle and poor contraction of the lower esophageal sphincter (LES). Dysphagia caused by scleroderma is often accompanied by heartburn.
    • Muscle spasms in the esophagus may occur spontaneously, and are often associated with chest pain. Instead of propelling swallowed food and liquid toward the stomach, these contractions block the movement of esophageal contents. In medical terms, these are referred to as diffuse esophageal spasms.

    Swallowing disorders in children are most commonly caused by structural conditions present at birth, and by disorders involving both the muscles and the nerves(neuromuscular conditions) such as muscular dystrophy.

    Many factors may contribute to dysphagia in older adults. Advancing age can be associated with poorly understood, age-related changes of esophageal motility. Many older adults also have dental problems and a generalized loss of muscle strength, and they may take a variety of drugs to treat specific medical conditions. All of these factors can contribute to dysphagia.

    Oropharyngeal and esophageal dysphagia typically produce different types of symptoms Table 02.

    • Oropharyngeal dysphagia is characterized by difficulty moving food or liquid to the back of the throat, and difficulty initiating a swallow. Food may accumulate in the mouth, spill out of the corners of the mouth, or move from the pharynx (the back of the mouth) into the nasal passages. Sometimes, food or liquid will actually move past the vocal cords and enter the trachea (windpipe), causing respiratory symptoms. A variety of other symptoms can accompany oropharyngeal dysphagia.
    • Esophageal dysphagia is characterized by a sensation that swallowed food or liquid is sticking in the esophagus somewhere near the neck or chest. Esophageal dysphagia often occurs as an isolated symptom, although it may be accompanied by other symptoms, depending on the underlying cause.

    Table 2.  Possible Signs of Swallowing Difficulties

    Difficulty chewing
    Difficulty initiating swallowing
    Difficulty moving food or liquid from the mouth into the throat
    Sensation that food is getting stuck in the mouth, throat, or esophagus
    Persistent sensation of a ?lump? in the throat
    Frequent need to clear the throat
    Generalized mouth or throat pain
    Pain during swallowing
    Drooling
    Coughing or choking when eating
    Bad breath
    Reflux of food or liquid into the throat, mouth, or nose
    Change in voice (nasal voice or hoarseness)
    Difficulty speaking
    Hiccups
    Dry mouth and/or throat
    Weight loss
    Heartburn
    Chest pain
    Ear pain
    Frequent respiratory tract infections
    Pneumonia

    Inability to swallow solids, liquids, or both can provide clues about the underlying cause of dysphagia. The consistency of food associated with dysphagia often provides clues about the underlying cause. People with oropharyngeal dysphagia often have more difficulty swallowing liquids, while people with structural causes of dysphagia often have more difficulty swallowing solids. If the person’s esophagus has difficulty producing the contractions to move food down to the stomach often he or she may have difficulty swallowing either solids or liquids.

    Long-standing dysphagia can lead to complications; it is important to be alert for symptoms of these complications. Longstanding dysphagia carries risks of malnutrition, dehydration, and movement of food or liquid into the airway (aspiration).

    • Malnutrition is characterized by marked weight loss and deficiencies of the vitamins, minerals, and nutrients needed for general health.
    • Dehydration results from loss of water and the essential body salts required for the body to function normally. Dehydration is characterized by a variety of signs and symptoms such as dry mouth, thirst, low blood pressure, decreased urine output and decreased skin elasticity.
    • Entry of swallowed material into the airway (aspiration) may cause coughing and choking, but it may also occur silently. Frequent upper respiratory tract infections and pneumonia can indicate that aspiration is occurring.

    Adults must be alert for the symptoms of swallowing difficulties in infants and children. Infants and children with dysphagia may have residual food or liquid in their mouths after eating, may turn their heads or make exaggerated facial expressions when attempting to eat, or may vomit. They may also cough or choke if food or liquid enters the airway. However, aspiration occurs without obvious symptoms in about 70% of children. Frequent upper respiratory tract infections or pneumonia in an infant or child may be the first indication of aspiration.

    Gastroesophageal reflux disease (GERD) increases the risk of inflammation of the esophagus (esophagitis), esophageal strictures, and esophageal cancer, all of which can cause swallowing difficulties. The chronic acid reflux of gastroesophageal reflux disease (GERD) often damages the esophageal lining. Inflammation of the esophagus (esophagitis) can cause dysphagia and pain during swallowing (odynophagia); over time, esophagitis can lead to narrowing (strictures) of the esophagus, and even esophageal cancer. Esophagitis, strictures, and esophageal cancer can all interfere with swallowing.

    Many drugs prescribed for various medical conditions may be associated with dysphagia. Dysphagia is a potential side effect of many drugs used to treat medical conditions. These drugs include central nervous system depressants (such as drugs used to treat anxiety or trouble sleeping), antipsychotics (used to treat psychosis), corticosteroids (a group of anti-inflammatory drugs that includes prednisone and is used to treat many diseases), lipid-lowering drugs (for people with high cholesterol), colchicines (used to treat gout and other medical conditions), aminoglycosides (a group of antibiotics), anticonvulsants (used to treat seizure disorders), and antihistamines (for allergies).

    Certain drugs can actually produce a chemical inflammation if they stay in contact with the esophageal lining for long periods of time. This inflammation is called pill esophagitis, and it can cause dysphagia. Certain antibiotics can cause pill esophagitis, such as tetracycline, doxycycline, and minocycline, as well as other drugs such as potassium chloride, iron supplements, vitamin C, and quinidine. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), zidovudine, and alendronate are also thought to cause to this burn.

    Certain hereditary conditions are associated with dysphagia. Hereditary conditions such as muscular dystrophy can lead to dysphagia because these patients lack the muscle control necessary for normal swallowing.

    The diagnosis of dysphagia begins with a medical history. A detailed medical history is essential for the diagnosis of dysphagia. In about 85% of people who consult a doctor for dysphagia, the medical history strongly hints at the underlying cause of dysphagia.

    A head and neck exam can help confirm the presence of dysphagia and provide clues about the underlying cause. During a head and neck exam, a doctor examines the lining of the mouth, the tongue, the roof of the mouth (palate), the teeth, the throat (pharynx), the voice box (larynx), the nose, and the neck. The doctor will test reflexes, motor function, muscle strength, and sensation, and check for symptoms such as collection of secretions and abnormal movement of the vocal cords.

    In some cases, a general physical exam is necessary to determine the cause of dysphagia. Many body-wide (systemic) conditions can affect swallowing. A general physical exam may detect signs and symptoms of neuromuscular disease, endocrine disorders, cancer, or autoimmune disease.

    Although many tests are available for confirming dysphagia and identifying the underlying cause, doctors choose specific tests based on the most likely diagnosis Table 03. A few tests will often confirm dysphagia and reveal the underlying cause. In some cases, a doctor may order additional tests if preliminary tests do not provide enough information.

    Table 3.  Tests Used to Diagnose Swallowing Difficulties

    Test What it can detect
    Barium swallow test and videofluoroscopy Can show structural abnormalities of the esophagus and/or throat. Videofluroscopy can visualize the act of swallowing and aspiration
    Fiberoptic endocscopy? May reveal inflammation of the esophagus, tumors, webs, rings, narrowing (strictures), pouches (diverticula)
    Manometry? Can determine how well the esophagus is moving food down to the stomach (esophageal motility)?
    Ultrasound? Can detect swallowing problems in infants and children and certain causes of esophageal dysphagia in adults
    Continuous pH monitoring For detecting acid reflux, which may be associated with dysphagia?
    Bolus (esophageal transit) scintigraphy Checks for entry of swallowed material into the airway (aspiration)?
    Computed tomography (CT) and magnetic resonance imaging (MRI) Looks for structures that compress the esophagus?

    The barium swallow test and videofluoroscopy are the most sensitive tests for detecting structural abnormalities. During the barium swallow test and videofluoroscopy (also called the videofluoroscopic swallow study [VFSS]), a person is asked to swallow barium in various forms ranging from liquid to semisolid to solid. During the barium swallow test (most useful for evaluating esophageal dysphagia), individual x-rays are taken. During videofluoroscopy (most useful for evaluating oropharyngeal dysphagia), serial x-rays are taken and then analyzed in slow motion.

    Because the x-rays show the mouth, throat, and esophagus as the barium moves from the mouth to the stomach, these tests are very sensitive for detecting structural causes of dysphagia, such as tumors, webs, strictures, rings, diverticula (the outward pouching of the wall of an organ or structure), and compression of the esophagus by external structures. The tests may also reveal impaired function of the esophagus and of the lower esophageal sphincter (LES). However, these tests are not very useful for detecting minor inflammation of the esophagus.

    Fiberoptic endoscopy is the most sensitive test for detecting inflammation of the esophagus (esophagitis). It is also very useful in detecting structural abnormalities of the inner lining of the esophagus, stomach and the first part of the small bowel (duodenum). During fiberoptic endoscopy, a thin, lighted tube is advanced through the mouth or nose, and the pharynx, esophagus, and stomach are viewed directly. This test is very helpful for detecting esophagitis. Furthermore, during this test, small samples of secretions, tissue, and cells can be collected for later laboratory analysis, and trapped foreign bodies can be retrieved through the endoscope.

    Manometry is very sensitive for detecting problems with esophageal movement (motility). During manometry, a pressure sensor is advanced into the pharynx and esophagus in order to detect abnormal contractile pressures during rest and swallowing. Manometry is useful for diagnosing conditions that affect how well the esophagus is able to contract and transport food, such as achalasia and diffuse esophageal spasms. This test can be performed during videofluoroscopy.

    Ultrasound is useful for identifying swallowing problems in infants and children, and certain causes of esophageal dysphagia in adults. In infants and children, an ultrasound probe applied to the cheek and upper neck can be used to view the action of the tongue and larynx during sucking and swallowing. In adults, the probe can be advanced into the esophagus and used to check for abnormal structures that are hidden within the esophageal wall.

    Continuous pH monitoring is useful for determining if acid reflux is associated with dysphagia. During continuous pH monitoring, a pH sensor is placed in the esophagus and used to record the pH (degree of acidity) over a 24-hour time period. The person may be asked to keep a diary noting the time when dysphagia occurs; later comparison of the diary and pH results may reveal that dysphagia and acid reflux occur at the same time.

    A test called bolus scintigraphy is useful for measuring esophageal transit (the time taken by the food to traverse the esophagus) and detecting aspiration. During bolus scintigraphy, a person is asked to swallow liquid that has been labeled with a radioactive material. The amounts of radioactive material in the esophagus and other structures can be measured over time. The test is very sensitive for detecting the entry of swallowed material into the airway (aspiration), but it is not routinely used during the evaluation of dysphagia.

    Computed tomography (CT) and magnetic resonance imaging (MRI) scans may be useful for identifying structures that compress the esophagus. The scans are painless, and offer more complete structural detail.

    Blood tests can help identify certain causes of dysphagia. Blood tests may be used to measure levels of thyroid-stimulating hormone, vitamin B12, and creatinine kinase. Blood tests may also reveal substances that signal the presence of myasthenia gravis, a neuromuscular disorder that can cause dysphagia.

    Functional dysphagia is not usually diagnosed until all other types of dysphagia have been ruled out. In rare cases, a person may have a sensation of a lump in the throat (called globus sensation) or a sensation of poor movement of swallowed food, but physical exams and diagnostic tests do not reveal any abnormality. This form of dysphagia is called functional (or psychogenic) dysphagia, and is usually diagnosed when careful testing reveals no physiologic or anatomic cause for the symptoms. Functional dysphagia can be caused by stress, and is often seen in conjunction with fainting, nausea, and fatigue.

    Following a few simple steps can help prevent irritation of the esophagus due to damage from swallowed pills (pill esophagitis). Pill esophagitis can usually be prevented by drinking 4 ounces of water, taking the pill with six to eight ounces of water, and then drinking another 4 ounces of water. Furthermore, pills should be taken at least 2 hours before going to bed and while sitting up or standing.

    Treatment of gastroesophageal reflux disease (GERD) may help prevent complications that lead to dysphagia. Gastroesophageal reflux disease (GERD) can cause esophagitis, strictures, and in severe cases, may even contribute to esophageal cancer, and all of these complications can impair swallowing. Successful treatment of GERD can halt ongoing injury of the esophagus, and may even reverse this injury in some cases. A doctor may recommend periodic screening endoscopy for people with moderate or severe GERD because they have an increased risk for complications.

    Minimize the risk factors for esophageal cancer. Smoking and consuming large amounts of alcohol have been shown to increase a person's risk of esophageal cancer. Quitting smoking and restricting alcohol intake to light or moderate amounts may reduce this risk.

    Supervise young children and “child-proof” your home. Because young children often place objects in their mouths, it is important to supervise them at all times and to ensure that they won't come in contact with dangerous items, such as small objects and cleaning solutions. A pediatrician can outline steps for “child-proofing” your home.

  • Prevention and Screening

    Following a few simple steps can help prevent irritation of the esophagus due to damage from swallowed pills (pill esophagitis). Pill esophagitis can usually be prevented by drinking 4 ounces of water, taking the pill with six to eight ounces of water, and then drinking another 4 ounces of water. Furthermore, pills should be taken at least 2 hours before going to bed and while sitting up or standing.

    Treatment of gastroesophageal reflux disease (GERD) may help prevent complications that lead to dysphagia. Gastroesophageal reflux disease (GERD) can cause esophagitis, strictures, and in severe cases, may even contribute to esophageal cancer, and all of these complications can impair swallowing. Successful treatment of GERD can halt ongoing injury of the esophagus, and may even reverse this injury in some cases. A doctor may recommend periodic screening endoscopy for people with moderate or severe GERD because they have an increased risk for complications.

    Minimize the risk factors for esophageal cancer. Smoking and consuming large amounts of alcohol have been shown to increase a person's risk of esophageal cancer. Quitting smoking and restricting alcohol intake to light or moderate amounts may reduce this risk.

    Supervise young children and “child-proof” your home. Because young children often place objects in their mouths, it is important to supervise them at all times and to ensure that they won't come in contact with dangerous items, such as small objects and cleaning solutions. A pediatrician can outline steps for “child-proofing” your home.

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