Dysphagia

DESCRIPTION

• Oropharyngeal: difficulty transferring food bolus from oropharynx to proximal esophagus
• Esophageal: difficulty moving food bolus through the body of the esophagus to the pylorus

EPIDEMIOLOGY

5–8% of the general population >50 years of age

ETIOLOGY AND PATHOPHYSIOLOGY

• Oropharyngeal (transfer dysphagia):
  • Functional motor disorder in the oropharynx
  • Mechanical: pharyngeal and laryngeal cancer, acute epiglottitis, carotid body tumor, pharyngitis, tonsillitis, strep throat, lymphoid hyperplasia of lingual tonsil, lateral pharyngeal pouch, hypopharyngeal diverticulum
  • Neuromyogenic: stroke, head trauma, Parkinson disease, amyotrophic lateral sclerosis (ALS), myasthenia, polymyositis, dermatomyositis, muscular dystrophies, thyrotoxicosis, hypothyroidism, amyloidosis, Cushing syndrome
  • Esophageal:
    • Mechanical: carcinomas, diverticula, webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body; eosinophilic esophagitis
    • Extrinsic mechanical: peritonsillar abscess, thyroid disorders, tumors, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), adenopathy, duplication cyst
• Neuromuscular: achalasia, spasm, hypertonic sphincter, scleroderma, CVA, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, polymyositis, dermatomyositis, neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyperthyroidism and hypothyroidism, Guillain-Barré syndrome, SLE, ALL, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease
  • Infections: diphtheria, meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, CMV, esophagitis (Candida, herpetic)

RISK FACTORS

• Children: hereditary and/or congenital malformations
• Adults: age >50 years; elderly: GERD, stroke, COPD, chronic pain
• Medications: quinine, potassium chloride, vitamin C, tetracycline, trimethoprim (Bactrim), clindamycin, NSAIDs, procainamide, anticholinergics, bisphosphates, seizure meds: phenobarbital, carbamazepine, and phenytoin; antihistaminics, TCA’s: amitriptyline, imipramine, anti-psychotics: haloperidol, phenothiazine, butyrophenone, thioxanthene; oxybutynin; opiates; rizatriptan; ACE, ARB, calcium channel blockers, β-blockers, α₂-agonist; HCTZ and chlorothiazide; cytotoxic, (antineoplastics; interferon-α, ribavirin); sibutramine; β₂-agonist bronchodilators, muscle relaxants
  • Xerostomia: ACE inhibitors, antiarrhythmics, antiemetics, diuretics, SSRI, sunitinib everolimus
  • Neurologic: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, ALS, Huntington chorea, dementia; HIV patients with CD4 cell count <100 cells/mm³
• Trauma or irradiation of head, neck, and chest; mechanical lesions; extrinsic mechanical lesions: lung, thyroid tumors, lymphoma, metastasis; iron deficiency
  • Smoking, excess alcohol intake, obesity

GENERAL PREVENTION

Liquid and soft food diet as appropriate

COMMONLY ASSOCIATED CONDITIONS

Peptic structure, esophageal webs and rings, carcinoma, history of stroke, dementia, pneumonia