Difficulty In Swallowing
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Dysphagia is difficulty in swallowing. Although classified under "
symptoms and signs Signs and symptoms are diagnostic indications of an illness, injury, or condition. Signs are objective and externally observable; symptoms are a person's reported subjective experiences. A sign for example may be a higher or lower temperature ...
" in
ICD-10 ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social cir ...
, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including
odynophagia Odynophagia is pain when swallowing. The pain may be felt in the mouth or throat and can occur with or without difficulty swallowing. The pain may be described as an ache, burning sensation, or occasionally a stabbing pain that radiates to the ...
, which is defined as painful swallowing, and
globus GLOBUS is a radar system in the town of Vardø in Vardø Municipality, Finnmark county, Norway. It is operated by the Norwegian Intelligence Service (NIS) and its official uses are primarily space observation and Arctic airspace monitoring for Nor ...
, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A
psychogenic A psychogenic effect is one that originates from the brain instead of other physical organs (i.e. the cause is psychological rather than physiological) and may refer to: *Psychogenic pain *Psychogenic disease *Psychogenic amnesia *Psychogenic coug ...
dysphagia is known as
phagophobia Phagophobia is a psychogenic dysphagia, a fear of swallowing.Shapiro J, Franko DL, Gagne A. Phagophobia: a form of psychogenic dysphagia. A new entity. Ann Otol Rhinol Laryngol 1997; 106: 286-290. It is expressed in various swallowing complaints w ...
.


Classification

Dysphagia is classified into the following major types: #
Oropharyngeal dysphagia Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of ...
# Esophageal and obstructive dysphagia # Neuromuscular symptom complexes # Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.


Signs and symptoms

Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease. When dysphagia goes undiagnosed or untreated, patients are at a high risk of
pulmonary aspiration Pulmonary aspiration is the entry of solid or liquid material such as pharyngeal secretions, food, drink, or stomach contents from the oropharynx or gastrointestinal tract, into the trachea and lungs. When pulmonary aspiration occurs during ea ...
and subsequent
aspiration pneumonia Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may incl ...
secondary to food or liquids going the wrong way into the lungs. Some people present with "silent aspiration" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and kidney failure. Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent
pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...
, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and patient complaint of swallowing difficulty. When asked where the food is getting stuck, patients will often point to the cervical (
neck The neck is the part of the body in many vertebrates that connects the head to the torso. It supports the weight of the head and protects the nerves that transmit sensory and motor information between the brain and the rest of the body. Addition ...
) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived. The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated. Pain on swallowing or
odynophagia Odynophagia is pain when swallowing. The pain may be felt in the mouth or throat and can occur with or without difficulty swallowing. The pain may be described as an ache, burning sensation, or occasionally a stabbing pain that radiates to the ...
is a distinctive symptom that can be highly indicative of
carcinoma Carcinoma is a malignancy that develops from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesoder ...
, although it also has numerous other causes that are not related to cancer.
Achalasia Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esopha ...
is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the Auerbach's (Myenteric) plexus of the entire esophagus, which results in functional narrowing of the lower
esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...
, and peristaltic failure throughout its length.


Complications

Complications of dysphagia may include aspiration,
pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...
,
dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...
, and weight loss.


Causes

The following table enumerates possible causes of dysphagia: Difficulty with or inability to swallow may be caused or exacerbated by the usage of opioids. Other drugs such as
cocaine Cocaine is a tropane alkaloid and central nervous system stimulant, derived primarily from the leaves of two South American coca plants, ''Erythroxylum coca'' and ''Erythroxylum novogranatense, E. novogranatense'', which are cultivated a ...
may also induce it.


Diagnosis

*
Esophagoscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...
and
laryngoscopy Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...
can give direct view of lumens. *
Esophageal motility study An esophageal motility study (EMS) or esophageal manometry is a test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES). Indications An EMS is typically done to evaluate susp ...
is useful in cases of esophageal achalasia and diffuse esophageal spasms. *
Exfoliative cytology Cytopathology (from Ancient Greek, Greek , ''kytos'', "a hollow"; , ''pathos'', "fate, harm"; and , ''-logy, -logia'') is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nico ...
can be performed on esophageal lavage obtained by esophagoscopy. It can detect malignant cells in early stage. *
Ultrasonography Medical ultrasound includes diagnostic techniques (mainly imaging) using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints, ...
and
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
are not very useful in finding causes of dysphagia, but can detect masses in mediastinum and aortic aneurysms. * FEES (Fibreoptic endoscopic evaluation of swallowing), sometimes with sensory evaluation, is done usually by a Medical Speech Pathologist or Deglutologist. This procedure involves the patient eating different consistencies as above. * Swallowing sounds and vibrations could be potentially used for dysphagia screening, but these approaches are in the early research stages.


Differential diagnosis

All causes of dysphagia are considered as differential diagnoses. Some common ones are: *
Esophageal atresia Esophageal atresia is a congenital medical condition (birth defect) that affects the alimentary tract. It causes the esophagus to end in a blind-ended pouch rather than connecting normally to the stomach. It comprises a variety of congenital anat ...
* Paterson-Kelly syndrome *
Zenker's diverticulum A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum or false diverticulum (only ...
*
Esophageal varices Esophageal varices are extremely Vasodilation, dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendenc ...
* Benign strictures *
Achalasia Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esopha ...
* Esophageal diverticula *
Scleroderma Scleroderma is a group of autoimmune diseases that may result in changes to the skin, blood vessels, muscles, and internal organs. The disease can be either localized to the skin or involve other organs, as well. Symptoms may include areas ...
*
Diffuse esophageal spasm Diffuse esophageal spasm (DES), also known as distal esophageal spasm, is a condition characterized by uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may cause sy ...
*
Polymyositis Polymyositis (PM) is a type of chronic inflammation of the muscles ( inflammatory myopathy) related to dermatomyositis and inclusion body myositis. Its name is derived . The inflammation of polymyositis is mainly found in the endomysial layer ...
* Webs and rings *
Esophageal cancer Esophageal cancer (American English) or oesophageal cancer (British English) is cancer arising from the esophagus—the food pipe that runs between the throat and the stomach. Symptoms often include dysphagia, difficulty in swallowing and weigh ...
*
Eosinophilic esophagitis Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate t ...
*
Hiatus hernia A hiatal hernia or hiatus hernia is a type of hernia in which abdominal Organ (anatomy), organs (typically the stomach) slip through the Thoracic diaphragm, diaphragm into the mediastinum, middle compartment of the chest. This may result in gas ...
, especially paraesophageal type *
Dysphagia lusoria Dysphagia lusoria (or Bayford-Autenrieth dysphagia) is an abnormal condition characterized by difficulty in swallowing caused by an aberrant right subclavian artery. It was discovered by David Bayford in 1761 and first reported in a paper by the sa ...
* Stroke * Fahr's disease *
Wernicke encephalopathy Wernicke encephalopathy (WE), also Wernicke's encephalopathy, or wet brain is the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vi ...
*
Charcot–Marie–Tooth disease Charcot-Marie-Tooth disease (CMT) is an inherited neurological disorder that affects the peripheral nerves responsible for transmitting signals between the brain, spinal cord, and the rest of the body. This is the most common inherited neuropath ...
*
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...
*
Multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...
*
Amyotrophic lateral sclerosis Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, Terminal illness, terminal neurodegenerative disease, neurodegenerative disorder that results i ...
*
Rabies Rabies is a viral disease that causes encephalitis in humans and other mammals. It was historically referred to as hydrophobia ("fear of water") because its victims panic when offered liquids to drink. Early symptoms can include fever and abn ...
*
Cervical Spondylosis Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense, it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenera ...
Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially, only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from
thickened fluids Thickened fluids and thickened drinks are often used for people with dysphagia, a disorder of swallowing function. The thicker consistency makes it less likely that individuals will aspirate while they are drinking. Individuals with difficulty s ...
if the person is more comfortable with those liquids, although, so far, there is no scientific study that proves that those thickened liquids are beneficial. Dysphagia may manifest as the result of
autonomic nervous system The autonomic nervous system (ANS), sometimes called the visceral nervous system and formerly the vegetative nervous system, is a division of the nervous system that operates viscera, internal organs, smooth muscle and glands. The autonomic nervo ...
pathologies including stroke and
ALS Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, terminal neurodegenerative disorder that results in the progressive loss of both upper and low ...
, or due to rapid iatrogenic correction of an electrolyte imbalance. In older adults, presbyphagia - the normal healthy changes in swallowing associated with age - should be considered as an alternative explanation for symptoms.


Treatments

There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders (swallowing therapist), primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist. The role of the members of the multidisciplinary team will differ depending on the type of swallowing disorder present. For example, the swallowing therapist will be directly involved in the treatment of a patient with
oropharyngeal dysphagia Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of ...
, while a gastroenterologist will be directly involved in the treatment of an esophageal disorder.


Treatment strategies

The implementation of a treatment strategy should be based on a thorough evaluation by the multidisciplinary team. Treatment strategies will differ on a patient to patient basis and should be structured to meet the specific needs of each individual patient. Treatment strategies are chosen based on a number of different factors including diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation and interest.


Oral vs. nonoral feeding

Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy. Some people with dysphagia, especially those nearing the end of life, may choose to continue eating and drinking orally even when it has been deemed unsafe. This is known as "risk feeding".


Swallowing difficulties in dementia

A 2018 Cochrane review found no certain evidence about the immediate and long-term effects of modifying the thickness of fluids for swallowing difficulties in people with dementia. While thickening fluids may have an immediate positive effect on swallowing and improving oral intake, the long-term impact on the health of the person with dementia should also be considered.


Treatment procedures

Compensatory treatment procedures are designed to change the flow of the food/liquids and eliminate symptoms but do not directly change the physiology of the swallow. * Postural techniques * Food consistency (diet) changes * Modifying volume and speed of food presentation * Technique to improve oral sensory awareness * Intraoral prosthetics Therapeutic treatment procedures – designed to change and/or improve the physiology of the swallow. * Oral and pharyngeal range-of-Motion exercises * Resistance exercises * Bolus control exercises * Swallowing maneuvers ** Supraglottic swallow ** Super-supraglottic swallow ** Effortful swallow ** Mendelsohn maneuver Patients may need a combination of treatment procedures to maintain a safe and nutritionally adequate swallow. For example, postural strategies may be combined with swallowing maneuvers to allow the patient to swallow in a safe and efficient manner. The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are rehabilitation of the swallow through oral motor exercises, texture modification of foods, thickening fluids and positioning changes during swallowing. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures.  However, in 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0–7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with carers and will lead to greater standardization of modified diets.There is also a larger movement within the field of Speech Language Pathology to begin advocating for Dysphagia to be elevated within the school setting as it is currently not considered necessary during a Speech-Language and oral evaluation of a child. However, proper nutrition, hydration, and ability to swallow is critical for child's academic, social, and personal success.


Epidemiology

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, and in patients who have had strokes. Dysphagia affects about 3% of the population.


Etymology

The word "dysphagia" is derived from the
Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...
''dys'' meaning bad or disordered, and the root ''phag-'' meaning "eat".


See also

*
Aphagia Aphagia is the inability or refusal to swallow. The word is derived from the Ancient Greek prefix α, meaning "not" or "without," and the suffix φαγία, derived from the verb φαγεῖν, meaning "to eat." It is related to dysphagia which is ...
*
MEGF10 Multiple EGF-like-domains 10 is a protein that in humans is encoded by the ''MEGF10'' gene. MEGF10 is a regulator of satellite cell myogenesis and interacts with Notch1 in myoblasts. It has been shown to be the cause of early-onset myopathy, ar ...
*
Pseudodysphagia Pseudodysphagia, in its severe form, is the irrational fear of swallowing or, in its minor form, of choking. The symptoms are psychosomatic, so while the sensation of difficult swallowing feels authentic to the individual, it is not based on a ...
, an irrational fear of swallowing or choking


References


External links

{{Authority control Symptoms and signs: Digestive system and abdomen Gastrointestinal tract disorders Otorhinolaryngology