Dysphagia

Basics

Subjective sensation of difficulty or abnormality of swallowing

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
  • Males to female (1.5:1)

Prevalence

  • 14–33% among community-dwelling individuals ≥65 years old
  • Up to 40% in hospital settings
  • 29–32% of patients in nursing homes
  • 44% in patients in geriatrics acute care
  • 60% in older patients that are institutionalized

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

There's more to see -- the rest of this topic is available only to subscribers.