Dysphagia

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Basics

Impaired passage of the alimentary bolus from the mouth to stomach (1)[C]

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

Incidence
Esophageal food impaction 25 per 100,000 persons per year

Prevalence
  • From 14% to 33% among community-dwelling individuals 65 years old or older.
  • In hospital settings can be as high as 40 percent.
  • Nursing home residents range from 29% to 32%.

Etiology and Pathophysiology

  • Oropharyngeal (transfer dysphagia):
    • Functional due to disordered motor function in the oropharynx
    • Mechanical causes: 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 and parkinsonism, amyotrophic lateral sclerosis, myasthenia, myopathies (polymyositis, dermatomyositis, muscular dystrophies), alcoholic, thyrotoxicosis, hypothyroidism, amyloidosis, Cushing syndrome
  • Esophageal:
    • Mechanical: Carcinomas, esophageal diverticula, esophageal webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body
    • Extrinsic mechanical lesions: Peritonsillar abscess, thyroid disorders, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis of the cervical spine, adenopathy, esophageal duplication cyst
  • Neuromuscular: Achalasia, diffuse esophageal spasm, hypertonic lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyper- and hypothyroidism, Guillain-Barré syndrome, systemic lupus erythematosus, acute lymphoblastic leukemia, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease
  • Infection: Diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, cytomegalovirus, esophagitis (Candida, herpetic)

Risk Factors

  • Children: hereditary and/or congenital malformations
  • Adults: age >50 years; elderly: gastroesophageal reflux disease (GERD), stroke, chronic obstructive pulmonary disease, chronic pain
  • Smoking, excess alcohol intake, obesity
  • Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, nonsteroidal anti-inflammatory drugs, procainamide, anticholinergics, bisphosphonates, anticonvulsants such as phenobarbital, carbamazepine and phenytoin; antihistamines, antidepressants, neuroleptics
  • Xerostomia is reported with angiotensin-converting enzyme (ACE) inhibitors, antiarrhythmics, antiemetics, diuretics, selective serotonin reuptake inhibitor.
  • Mucositis by cytotoxic chemotherapy, and molecular target treatment as sunitinib, everolimus
  • Neurologic events or diseases: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (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
  • Anterior cervical spine surgery (up to 71% in the first 2 weeks postop; 12–14% at 1 year postop)
  • Dysphagia lusoria (vascular abnormalities causing dysphagia): complete vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic arch with mirror-image branching and left ligamentum arteriosum

General Prevention

  • Correct poorly fitting dentures.
  • Educate patients to prolong chewing and drink adequate volumes of water at meals.
  • Liquid and soft food diet as appropriate
  • Avoid alcohol with meals.
  • Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation

Commonly Associated Conditions

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

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Basics

Impaired passage of the alimentary bolus from the mouth to stomach (1)[C]

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

Incidence
Esophageal food impaction 25 per 100,000 persons per year

Prevalence
  • From 14% to 33% among community-dwelling individuals 65 years old or older.
  • In hospital settings can be as high as 40 percent.
  • Nursing home residents range from 29% to 32%.

Etiology and Pathophysiology

  • Oropharyngeal (transfer dysphagia):
    • Functional due to disordered motor function in the oropharynx
    • Mechanical causes: 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 and parkinsonism, amyotrophic lateral sclerosis, myasthenia, myopathies (polymyositis, dermatomyositis, muscular dystrophies), alcoholic, thyrotoxicosis, hypothyroidism, amyloidosis, Cushing syndrome
  • Esophageal:
    • Mechanical: Carcinomas, esophageal diverticula, esophageal webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body
    • Extrinsic mechanical lesions: Peritonsillar abscess, thyroid disorders, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis of the cervical spine, adenopathy, esophageal duplication cyst
  • Neuromuscular: Achalasia, diffuse esophageal spasm, hypertonic lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyper- and hypothyroidism, Guillain-Barré syndrome, systemic lupus erythematosus, acute lymphoblastic leukemia, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease
  • Infection: Diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, cytomegalovirus, esophagitis (Candida, herpetic)

Risk Factors

  • Children: hereditary and/or congenital malformations
  • Adults: age >50 years; elderly: gastroesophageal reflux disease (GERD), stroke, chronic obstructive pulmonary disease, chronic pain
  • Smoking, excess alcohol intake, obesity
  • Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, nonsteroidal anti-inflammatory drugs, procainamide, anticholinergics, bisphosphonates, anticonvulsants such as phenobarbital, carbamazepine and phenytoin; antihistamines, antidepressants, neuroleptics
  • Xerostomia is reported with angiotensin-converting enzyme (ACE) inhibitors, antiarrhythmics, antiemetics, diuretics, selective serotonin reuptake inhibitor.
  • Mucositis by cytotoxic chemotherapy, and molecular target treatment as sunitinib, everolimus
  • Neurologic events or diseases: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (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
  • Anterior cervical spine surgery (up to 71% in the first 2 weeks postop; 12–14% at 1 year postop)
  • Dysphagia lusoria (vascular abnormalities causing dysphagia): complete vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic arch with mirror-image branching and left ligamentum arteriosum

General Prevention

  • Correct poorly fitting dentures.
  • Educate patients to prolong chewing and drink adequate volumes of water at meals.
  • Liquid and soft food diet as appropriate
  • Avoid alcohol with meals.
  • Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation

Commonly Associated Conditions

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

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