Dysphagia is difficulty in swallowing. It may be oropharyngeal dysphagia or oesophageal dysphagia
Causes
Oropharyngeal dysphagia
- Neurological: stroke, parkinson’s, dementia, multiple sclerosis, Guillianbarre, myasthenia, cerebral palsy, tardive dyskinesia, brain tumours, trauma
- Myopathy: connective tissue diseases, sarcoidosis, dermatomyositis
- Structural: Zenker’s diverticulum, webs, oropharyngeal tumours, osteophytes
- Infections: syphilis botulism, rabies, mucositis
- Metabolic: Cushing’s, thyrotoxicosis, Wilson’s disease
- Iatrogenic: chemotherapy, neuroleptics, post surgery, post radiation
Oesophageal dysphagia
- Tumours: cancer of the oesophagus
- Oesophagiitis: gastroesophageal reflux disease, candidiasis, pill oesophagitis (e.g. doxycycline), caustic soda injury
- Extrinsic compression: tumors, lymph nodes
- Motility: achalasia, scleroderma, oesophageal spasms
Clinical presentation
- Difficulty initiating a swallow, repetitive swallowing
- Nasal regurgitation
- Coughing, nasal speech, drooling
- Diminished cough reflex
- Choking (aspiration may occur without concurrent choking or coughing)
- Dysarthria and diplopia (may accompany neurologic conditions that cause oropharyngeal dysphagia)
- Halitosis in patients with a large, residue-containing Zenker’s diverticulum or in patients with advanced
achalasia or long-term obstruction with luminal accumulation of decomposing residue - Recurrent pneumonia
- Other features due to causative problem
Investigations
- Medical history and physical examination
- Timed water swallow test (complemented by a food test)
- Endoscopy (mandatory)
- HIV serology, RBS, electrolytes
Management
- Ensure rehydration with IV fluids
- Prevent malnutrition through appropriate energy replacement
- Treat cause if possible (e.g. fluconazole trial in case of suspected oral candidiasis among HIV
patients) - Consult and/or refer the patient