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 greater
• In hospital settings, can be as high as 40%
• Nursing home residents range from 29% to 32%.
• 30–40% in older people living independently
• 44% in patients in geriatrics acute care
• 60% in older patients that are institutionalized

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, CMV, esophagitis (Candida, herpetic)

Risk Factors

• Children: hereditary and/or congenital malformations
• Adults: age >50 years; elderly: GERD, stroke, COPD, chronic pain
• Smoking, excess alcohol intake, obesity
• Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, NSAIDs, procainamide, anticholinergics, bisphosphates, anticonvulsants (phenobarbital, carbamazepine, and phenytoin); antihistaminics, antidepressants (amitriptyline, imipramine), antipsychotics (haloperidol, phenothiazine, butyrophenone, thioxanthene); drugs for overactive bladder oxybutynin; opiates; antimigraine drugs such as rizatriptan; antihypertensive (ACE, ARB, calcium channel blockers, β-blockers, α₂-agonist); diuretics (HCTZ and chlorothiazide); cytotoxic (antineoplastics; interferon-α, ribavirin); appetite suppressants sibutramine; β₂-agonist bronchodilators, muscle relaxants
• Xerostomia is reported with ACE inhibitors, antiarrhythmics, antiemetics, diuretics, SSRI.
• 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