Resident Editor: Alfredo Aguirre, MD

Faculty Editor: Najwa El-Nachef, MD

Background

• Dysphagia is defined as difficulty or an abnormality in swallowing.
• Dysphagia is an alarm symptom which merits prompt evaluation. Dysphagia is NOT a normal consequence of aging.
• Symptom occurs in up to 3% of the population, although increases with age. Affects up to 30% of elderly adults and 50% of institutionalized elderly population.
• Predisposes to malnutrition, sarcopenia, dehydration, aspiration pneumonia/pneumonitis.
• Can be a clue to serious underlying illness, such as malignancy and systemic autoimmune disease.

Signs and Symptoms

• History helps guide differential diagnosis and work-up.
• Distinguish dysphagia from odynophagia (pain with swallowing) and globus sensation (functional disorder characterized by sensation of “lump” or food in the neck independent of swallowing, present between meals and not explained by GERD, structural disease or motility disorder).
• Distinguish between oropharyngeal and esophageal dysphagia with the following questions:
  • What happens when you try to swallow?
  • Do you have trouble chewing your food? Can help differentiate true dysphagia from oral cavity pathology (which is especially common in elderly due to poor dentition, xerostomia, TMJ disease, etc…)
  • Do you have difficulty swallowing solids, liquids or both? Solids > liquids suggests mechanical problem.
• Oropharyngeal dysphagia symptoms: difficulty in transferring food bolus from mouth to esophagus.
  • Difficulty initiating swallowing
  • Aspiration
  • Choking
  • Drooling
  • Dysphonia
  • Nasopharyngeal regurgitation
• Esophageal dysphagia: difficulty moving bolus from esophagus to stomach.
  • Food slowing down
  • Sensation of food “sticking”: some patients will localize to throat, which might be confused with oropharyngeal symptoms
  • Regurgitation
  • Odynophagia
  • Solids > liquids: suggests mechanical etiology
  • Liquids = solids: suggests motility disturbance
  • Respiratory symptoms uncommon (can be seen in advanced disease)

Differential Diagnosis

• Differential can be broken down into structural and neuromuscular causes.
• Most common cause of acute dysphagia in adults: food impaction.
• Oropharyngeal dysphagia:
  • Structural:
    • Zencker’s diverticulum
    • Proximal strictures
    • Malignancy
    • Goiter
    • XRT injury
    • Cervical osteophytes
    • Infection
    • Post-intubation
  • Neuromuscular:
    • CNS disease (dementia, stroke, Parkinson’s, ALS)
    • Myopathies
    • Connective tissue disease
• Esophageal dysphagia:
  • Structural:
    • Malignancy (esophageal, gastric, mediastinal)
    • Rings and webs
    • Peptic strictures
    • Foreign body/food impaction
    • Esophagitis
    • Eosinophilic esophagitis
    • Reflux esophagitis
    • XRT esophagitis
    • Pill esophagitis: tetracycle, quinine, bisphosphonates, KCl, vitamin C
    • Infectious esophagitis: CMV, HSV, Candida
  • Neuromuscular:
    • Achalasia
    • Esophageal hypomotility associated with scleroderma, DM, amyloid, hypothyroidism
    • Esophageal spasm
    • Infections (Chagas)

Evaluation

• Review medication list for drugs associated with:
  • Xerostomia: psychiatric medications and anticholinergics
  • Esophageal damage: tetracycline, KCl, NSAIDs, bisphosphonates
  • Dysmotility: opioids, CCB, nitrates
• Review allergies: food allergies may be suggestive of eosinophilic esophagitis
• Physical exam with bedside swallow to assess for regurgitation, drooling, etc...

• Oropharyngeal dysphagia
• 1^st step: modified barium swallow
  • Helpful to assess swallowing mechanics and identify structural lesions
  • Can assess aspiration risk
• Fiberoptic endoscopic evaluation of swallowing (FEES):
  • Can r/o structural lesion and evaluate swallow mechanics; penetration/aspiration risk perceived to be higher than with barium swallow (unclear if this translates to greater aspiration risk)
• ENT evaluation: if concerned for structural lesion
• Consider: EGD

• Esophageal dysphagia
• 1^st step: EGD
  • Can r/o structural disease, esophagitis
  • Biopsies can be taken to rule out eosinophilic esophagitis
• Modified barium swallow:
  • Can reveal subtle strictures
  • “Birds beak” (achalasia) or “corkscrew” (diffuse esophageal spasm) signs
• Manometry if no structural lesion
  • In this study, transnasal probe introduced into esophagus with pressure sensors. Typical protocol involved patient swallowing water in supine position.
  • Best test for evaluating peristalsis

Treatment

• Treatment focused on addressing underlying disorder:
  • PPI for treatment of reflux esophagitis
  • Certain structural lesions such as strictures and webs can be dilated endoscopically
  • Elimination diet vs. topical steroids for eosinophilic esophagitis
  • Treatment of motility disorders dependent on manometry findings

• Tenets of therapy for oropharyngeal dysphagia in elderly patients:
• Oral hygiene: suboptimal hygiene associated with aspiration PNA in patients with dysphagia. Recommend tooth brushing after meals, cleaning dentures once daily, mouthwashes, regular professional oral care.
• Compensatory measures: eat slowly and in small amounts, concentrate on swallowing and eliminate distractions, avoid mixing food and liquid in same mouthful, alternate liquids and solids to “wash down” residue, use sauces/gravy to facilitate bolus formation.
• Diet modifications: thickened liquids have been shown to reduce aspiration, but at the price of adherence and dehydration. Nectar viscosity is best tolerated. Solid diets can also be modified per patient need.
• Swallow postures: eat in upright position during meal and for at least 30 min afterwards. Chin tuck can be helpful (helps close airway).
• Referral to speech pathology: for the above and swallow rehabilitation

When to Refer

• Maintain high index of suspicion for foreign body ingestion in patients presenting with acute-onset dysphagia.
• Refer elderly patients with oropharyngeal dysphagia to Speech pathology for education and rehabilitation.
• Refer patients with suspected structural or neuromuscular disorders to Gastroenterology, though may ultimately benefit from multidisciplinary team including Thoracic Surgery, Oncology, Rheumatology and/or Neurology.

References

Baijens, et al. European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging. 2016; 11: 1403–1428.

Clavé, et al. Dysphagia: current reality and scope of the problem. Nat Rev Gastroenterol Hepatol. 2015 May;12(5):259-70.

Jansson-Knodell, CL, et al. Making Dysphagia Easier to Swallow: A Review for the Practicing Clinician. Mayo Clin Proc. 2017;92(6):965-972.