DYSPHAGIA

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