Dysphagia

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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

  • 10–30% among community-dwelling individuals ≥65 years old
  • Up to 40% in hospital settings
  • ~30% of patients in nursing homes
  • ~40% in patients in geriatrics acute care
  • 60% in older patients that are institutionalized
  • ~20% in postextubation patients in ICU

Etiology and Pathophysiology

  • Oropharyngeal (transfer) dysphagia—difficulty initiating swallowing; coughing; aspiration
    • Functional motor disordered 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 dysphagia—sensation of food getting stuck
    • 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, (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)

Genetics

Charge syndrome:

  • 22q11.2 (diGeorge Syndrome)
  • Microduplication of 11q13.3–FGF3 and FGF4 genes
  • Germline gain of function mutation in KIT gene
  • Polymorphisms of COMT and BDMF genes can contribute to dysphagia in older adults

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, TCAs: amitriptyline, imipramine; antipsychotics: haloperidol, phenothiazine, butyrophenone, thioxanthene; xybutynin; 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; cytotoxic, 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

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