Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under “symptoms and signs” in ICD-10, the term is sometimes used as a condition in its own right. People with dysphagia are sometimes unaware of having it.
It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A psychogenic dysphagia is known as phagophobia.
Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, in patients who have had strokes, and in patients who are admitted to acute care hospitals or chronic care facilities. Dysphagia is a symptom of many different causes, which can usually be elicited through a careful history by the treating physician. A formal oropharyngeal dysphagia evaluation is performed by a medical speech pathologist or occupational therapist. The word “dysphagia” is derived from the Greek dys meaning bad or disordered, and the root phag- meaning “eat”.
Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease. When dysphagia goes undiagnosed or untreated, patients are at a high risk of pulmonary aspiration and subsequent aspiration pneumonia secondary to food or liquids going the wrong way into the lungs. Some people present with “silent aspiration” and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and renal failure.
Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty).
When asked where the food is getting stuck, patients will often point to the cervical (neck) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.
The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as ‘becoming stuck’ or ‘held up’ before it either passes into the stomach or is regurgitated. Pain on swallowing or odynophagia is a distinctive symptom that can be highly indicative of carcinoma, although it also has numerous other causes that are not related to cancer.
Achalasia is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the Auerbach’s (Myenteric) plexus of the entire esophagus, which results in functional narrowing of the lower esophagus, and peristaltic failure throughout its length.
Complications of dysphagia may include aspiration, pneumonia, dehydration, and weight loss.
Dysphagia is classified into the following major types:
- Oropharyngeal dysphagia
- Esophageal and obstructive dysphagia
- Neuromuscular symptom complexes
- Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.
Opiates, bad news
Difficulty with or inability to swallow may be caused or exacerbated by usage of opiate and/or opioid drugs. In people admitted to hospital, a bedside “water swallow test” is often performed to determine whether there might be need for more detailed swallowing assessment. The test is more reliable when larger amounts of fluid are used. When assessing the swallowing, the test is abnormal if there is coughing or choking, or if the voice changes because of aspirated fluid resting on the vocal cords.
The gold-standard of diagnosing dysphagia is to perform an instrumental evaluation, as the area of interest is not visible to the eye, and the person may not accurately sense the dysphagia or localize where the problem is.
One of the gold-standards for diagnosing oropharyngeal dysphagia is the modified barium swallow study (MBSS), also known as the videofluoroscopic swallow study (VFSS/fluoroscopy). This is a lateral and anterior-posterior (AP) view of a motion x-ray that provides objective information on the structure and physiology of the swallow. The oral, pharyngeal and esophageal phases of the swallow are analyzed. Oral phase components that are evaluated are: lip closure, bolus control, initiation of lingual movement, mastication, bolus transport, and oral residue after the swallow. Pharyngeal phase issues that are examined are: velopharyngeal closure, initiation of the pharyngeal swallow, laryngeal elevation, anterior hyoid movement, epiglottic inversion, laryngeal vestibule closure and reaction times, tongue base retraction, pharyngeal constriction or stripping wave, and pharyngeal residue after the swallow. The esophagus is analyzed for clearance versus retention of food, liquids and a barium pill. Any retention is monitored to see if it returns to the upper esophagus or back to the pharynx and airway. The clinician tests a variety of foods, liquids, and potentially a barium tablet. It is important to test a variety of viscosities and volumes. Typically the test involves a thin/regular liquid, a mildly thick/nectar thick liquid, a moderately thick/honey thick liquid, a pudding/puree, a cracker or cookie, a mixed consistency, and a barium pill taken with liquid or with a puree (depending on the person’s baseline method). The clinician determines if the swallow is safe (lack of aspiration) and efficient (lack of residue). The goal is to figure out why the person is having difficulty swallowing and to figure out what can be done to improve safety and efficiency. Sometimes regular liquids can easily cause aspiration, and the clinician can test various maneuvers, postures, and safe swallow strategies to prevent aspiration depending on that person’s specific anatomy and physiology. One method to potential improve the safety of the liquid bolus is to alter the consistency of bolus (i.e., thickening the liquid to mildly thick/nectar thick liquid, moderately thick/honey thick liquid, or extremely thick/pudding thick liquid). If there is a lot of residue after the swallow, there are also techniques that will be tested to reduce this. See treatment section below for more on compensatory strategies versus rehabilitation techniques for the swallow.
Another gold-standard for diagnosing dysphagia is the Fiberoptic Endoscopic Evaluation of Swallowing (FEES). This involves similar testing of foods and liquids, along with implementation of strategies to find out why the dysphagia is occurring and what can be done about it. The duration of the examination is not limited by radiation exposure; therefore, the person could be watched in a more natural environment over the course of a meal. The endoscope is very thin and usually well tolerated even without numbing the nose.
A barium swallow study/esophagram/upper GI study can best evaluate the entire esophagus. The barium is given in large volumes to fully distend and evaluate the esophageal lumen. This study can also evaluate for reflux, unlike the VFSS. A Zenker’s diverticulum can be seen on the VFSS and on an esophagram. The, barium may fills the pouch and then overflow, with food/liquid returning to the pharynx with risk for aspiration after the swallow. Achalasia is best evaluated on the barium swallow/esophagram, and it shows “bird-beak” tapering of distal esophagus, this is also described as a “rat’s tail” appearance. In esophageal strictures, liquid barium may remain above the stricture and then gradually trickles down. Strictures can sometimes be seen on a VFSS if the clinician suspects stricture or esophageal dysmotility. The clinician can scan down the esophagus after giving solid foods like cookie or bread. It is helpful to scan the esophagus on the VFSS as this is the exam that can test a full array of solids. The barium swallow/esophagram typically only tests barium liquids and a barium tablet.
- Esophagoscopy and laryngoscopy can give direct view of lumens.
- Chest radiograph may show air-fluid level in mediastinum. Pott’s disease and calcified aneurysms of aorta can be easily diagnosed.
- Esophageal motility study is useful in cases of achalasia and diffuse esophageal spasms.
- Exfoliative cytology can be performed on esophageal lavage obtained by esophagoscopy. It can detect malignant cells in early stage.
- Ultrasonography and CT scan are not very useful in finding cause of dysphagia; but can detect masses in mediastinum and aortic aneurysms.
- FEES (Fibreoptic endoscopic evaluation of swallowing), sometimes with sensory evaluation, is done usually by a Medical Speech Pathologist or Deglutologist. This procedure involves the patient eating different consistencies as above.
- Swallowing sounds and vibrations could be potentially used for dysphagia screening, but these approaches are in the early research stages.
All causes of dysphagia are considered as differential diagnoses. Some common ones are:
- Esophageal atresia
- Paterson-Kelly syndrome
- Zenker’s diverticulum
- Esophageal varices
- Benign strictures
- Esophagial diverticula
- Diffuse esophageal spasm
- Webs and rings
- Esophageal cancer
- Eosinophilic esophagitis
- Hiatus hernia, especially paraesophageal type
- Dysphagia lusoria
- Gastroesophageal reflux
- Parkinson’s disease
- Multiple Sclerosis
Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from thickened fluids if the person is more comfortable with those liquids, although, so far, there are no scientific study that proves that those thickened liquids are beneficial.
Dysphagia may manifest as the result of autonomic nervous system pathologies including stroke and ALS, or due to rapid iatrogenic correction of an electrolyte imbalance.
There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders (swallowing therapist), primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist. The role of the members of the multidisciplinary team will differ depending on the type of swallowing disorder present. For example, the swallowing therapist will be directly involved in the treatment of a patient with oropharyngeal dysphagia, while a gastroenterologist will be directly involved in the treatment of an esophageal disorder.
The implementation of a treatment strategy should be based on a thorough evaluation by the multidisciplinary team. Treatment strategies will differ on a patient to patient basis and should be structured to meet the specific needs of each individual patient. Treatment strategies are chosen based on a number of different factors including diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation and interest.
Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain, or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy.
Compensatory Treatment Procedures – designed to change the flow of the food/liquids and eliminate symptoms, do not directly change the physiology of the swallow. Postural Techniques Food Consistency (Diet) Changes Modifying Volume and Speed of Food Presentation Technique to Improve Oral Sensory Awareness Intraoral Prosthetics
Therapeutic Treatment Procedures – designed to change and/or improve the physiology of the swallow. Oral and Pharyngeal Range-of-Motion Exercises Resistance Exercises Bolus Control Exercises Swallowing Maneuvers Supraglottic swallow Super-supraglottic swallow Effortful swallow Mendelsohn maneuver
Patients may need a combination of treatment procedures to maintain a safe and nutritionally adequate swallow. For example, postural strategies may be combined with swallowing maneuvers to allow the patient to swallow in a safe and efficient manner.
The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are texture modification of foods, thickening fluids and positioning changes during swallowing. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures. However, in 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0-7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with carers and will lead to greater standardisation of modified diets
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- Smithard DG, Smeeton NC, Wolfe CD (January 2007). “Long-term outcome after stroke: does dysphagia matter?”. Age and Ageing. 36 (1): 90–4. doi:10.1093/ageing/afl149. PMID 17172601.
- Brady A (January 2008). “Managing the patient with dysphagia”. Home Healthcare Nurse. 26 (1): 41–6, quiz 47–8. doi:10.1097/01.NHH.0000305554.40220.6d. PMID 18158492.
- “ICD-10”. Retrieved 2008-02-23.
- Boczko F (November 2006). “Patients’ awareness of symptoms of dysphagia”. Journal of the American Medical Directors Association. 7 (9): 587–90. doi:10.1016/j.jamda.2006.08.002. PMID 17095424.
- “Dysphagia”. University of Virginia. Archived from the original on 2004-07-09. Retrieved 2008-02-24.
- “Swallowing Disorders – Symptoms of Dysphagia”. New York University School of Medicine. Archived from the original on 2007-11-14. Retrieved 2008-02-24.
- Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG (2004). “Awareness of dysphagia by patients following stroke predicts swallowing performance”. Dysphagia. 19 (1): 28–35. doi:10.1007/s00455-003-0032-8. PMID 14745643.
- Rosenvinge SK, Starke ID (November 2005). “Improving care for patients with dysphagia”. Age and Ageing. 34 (6): 587–93. doi:10.1093/ageing/afi187. PMID 16267184.
- Sleisenger, Marvin H.; Feldman, Mark; Friedman, Lawrence M. (2002). Sleisenger & Fordtran’s Gastrointestinal & Liver Disease, 7th edition. Philadelphia, PA: W.B. Saunders Company. Chapter 6, p. 63. ISBN 978-0-7216-0010-9.
- “Dysphagia”. University of Texas Medical Branch. Archived from the originalon 2008-03-06. Retrieved 2008-02-23.
- Logemann, Jeri A. (1998). Evaluation and treatment of swallowing disorders. Austin, Tex: Pro-Ed. ISBN 978-0-89079-728-0.
- Spieker MR (June 2000). “Evaluating dysphagia”. American Family Physician. 61 (12): 3639–48. PMID 10892635.
- “Opioid Effects on Swallowing and Esophageal Sphincter Pressure”. clinicaltrials.gov. US National Library of Medicine. Retrieved 23 March 2018.
- Brodsky, Martin B.; Suiter, Debra M.; González-Fernández, Marlís; Michtalik, Henry J.; Frymark, Tobi B.; Venediktov, Rebecca; Schooling, Tracy (July 2016). “Screening accuracy for aspiration using bedside water swallow tests”. Chest. 150 (1): 148–163. doi:10.1016/j.chest.2016.03.059. PMC 4980548. PMID 27102184.
- Chen, PC; Chuang, CH; Leong, CP; Guo, SE; Hsin, YJ (November 2016). “Systematic review and meta-analysis of the diagnostic accuracy of the water swallow test for screening aspiration in stroke patients”. Journal of advanced nursing. 72 (11): 2575–2586. doi:10.1111/jan.13013. PMID 27237447.
- Dudik JM, Coyle JL, Sejdić E (August 2015). “Dysphagia Screening: Contributions of Cervical Auscultation Signals and Modern Signal-Processing Techniques”. IEEE Transactions on Human-Machine Systems. 45 (4): 465–477. doi:10.1109/thms.2015.2408615. PMC 4511276. PMID 26213659.
- Edmiaston J, Connor LT, Loehr L, Nassief A (July 2010). “Validation of a dysphagia screening tool in acute stroke patients”. American Journal of Critical Care. 19 (4): 357–64. doi:10.4037/ajcc2009961. PMC 2896456. PMID 19875722.
- Noh EJ, Park MI, Park SJ, Moon W, Jung HJ (July 2010). “A case of amyotrophic lateral sclerosis presented as oropharyngeal Dysphagia”. Journal of Neurogastroenterology and Motility. 16 (3): 319–22. doi:10.5056/jnm.2010.16.3.319. PMC 2912126. PMID 20680172.
- Martin RJ (September 2004). “Central pontine and extrapontine myelinolysis: the osmotic demyelination syndromes”. Journal of Neurology, Neurosurgery, and Psychiatry. 75 Suppl 3: iii22–8. doi:10.1136/jnnp.2004.045906. PMC 1765665. PMID 15316041.
- McCurtin A, Healy C (February 2017). “Why do clinicians choose the therapies and techniques they do? Exploring clinical decision-making via treatment selections in dysphagia practice”. International Journal of Speech-Language Pathology. 19(1): 69–76. doi:10.3109/17549507.2016.1159333. PMID 27063701.
- O’Keeffe ST (July 2018). “Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?”. BMC Geriatrics. 18 (1): 167. doi:10.1186/s12877-018-0839-7. PMC 6053717. PMID 30029632.
- Cichero JA, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, Duivestein J, Kayashita J, Lecko C, Murray J, Pillay M, Riquelme L, Stanschus S (April 2017). “Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework”. Dysphagia. 32 (2): 293–314. doi:10.1007/s00455-016-9758-y. PMC 5380696. PMID 27913916.
- Shamburek RD, Farrar JT (February 1990). “Disorders of the digestive system in the elderly”. The New England Journal of Medicine. 322 (7): 438–43. doi:10.1056/NEJM199002153220705. PMID 2405269.
- “When the Meal Won’t Go Down”. New York Times. April 21, 2010. Retrieved July 27, 2014.
- Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (December 2005). “Dysphagia after stroke: incidence, diagnosis, and pulmonary complications”. Stroke. 36 (12): 2756–63. doi:10.1161/01.STR.0000190056.76543.eb. PMID 16269630.
- Ingelfinger FJ, Kramer P, Soutter L, Schatzki R (February 1959). “Panel discussion on diseases of the esophagus”. The American Journal of Gastroenterology. 31 (2): 117–31. PMID 13617241.