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Dysphagia refers to difficulty swallowing, which can occur at any stage of the swallowing process and can affect both the oropharyngeal and oesophageal phases. Identifying the cause of dysphagia is critical for appropriate management and treatment.

Types of Dysphagia

Oropharyngeal Dysphagia

This type involves difficulty initiating a swallow and is usually related to problems with the mouth or throat.

• Causes: Neurological disorders (e.g., stroke, Parkinson’s disease, multiple sclerosis), structural abnormalities (e.g., tumors, Zenker’s diverticulum), muscular disorders (e.g., myasthenia gravis), or radiation therapy.
• Symptoms: Coughing, choking, nasal regurgitation, aspiration, and difficulty controlling food or liquids in the mouth.

Oesophageal Dysphagia

This involves difficulty in the passage of food down the oesophagus after it has been initiated.

• Causes: Mechanical obstruction (e.g., oesophageal stricture, tumours, oesophageal webs, Schatzki’s ring), motility disorders (e.g., achalasia, diffuse oesophageal spasm), or gastr oesophageal reflux disease (GERD).
• Symptoms: Sensation of food getting stuck in the chest or throat, regurgitation, chest pain, or heartburn.

Clinical Approach to Dysphagia

History

• Duration and Onset: Determine whether the dysphagia is acute, subacute, or chronic.
• Type of Food Affected: Ask whether the difficulty is with solids, liquids, or both.
• Associated Symptoms: Symptoms such as weight loss, odynophagia (pain with swallowing), cough, or aspiration help narrow the differential diagnosis.
• Neurological Symptoms: Identify any signs of neurological deficits such as weakness, slurred speech, or cranial nerve involvement.
• History of GERD or Surgery: Prior history of reflux, Barrett’s oesophagus, or oesophageal surgery may be contributory.

2. Physical Examination

• Oral and Pharyngeal Exam: Look for signs of structural abnormalities, poor muscle coordination, or signs of infection.
• Neurological Examination: Evaluate cranial nerves and assess for signs of stroke, neuromuscular disease, or other neurological conditions.
• General Exam: Look for signs of malnutrition, weight loss, or dehydration that may suggest chronic dysphagia.

Diagnostic Tests

• Barium Swallow: A radiographic test to evaluate the structure and function of the oesophagus and detect obstructions, strictures, or motility disorders.
• Upper Endoscopy (EGD): A direct visualization of the oesophagus, useful for diagnosing structural lesions like tumours, strictures, or oesophagitis.
• Manometry: Measures oesophageal motility and is essential for diagnosing motility disorders like achalasia or oesophageal spasm.
• Video fluoroscopic Swallow Study (VFSS): Helps evaluate the oral and pharyngeal phases of swallowing and identifies aspiration or swallowing dysfunction.
• pH Monitoring: Used in suspected GERD-related dysphagia to assess acid exposure in the oesophagus.

Management of Dysphagia

Oropharyngeal Dysphagia

• Speech and Swallow Therapy: Particularly useful in patients with neurological causes of dysphagia (e.g., post-stroke patients). Techniques to improve swallowing safety and efficiency are taught.
• Dietary Modifications: Thickened liquids and soft foods are often prescribed to reduce the risk of aspiration.
• Medical/Surgical Management: Treat underlying causes like infections, tumours, or structural abnormalities (e.g., cricopharyngeal myotomy in Zenker’s diverticulum).

Oesophageal Dysphagia

• Mechanical Obstructions: Depending on the cause, endoscopic dilation or surgery may be necessary for strictures, tumours, or webs.
• Motility Disorders: Pharmacological treatments (e.g., calcium channel blockers for oesophageal spasm) or endoscopic procedures like botulinum toxin injection in achalasia. In severe cases, surgical interventions like Heller myotomy may be indicated.
• GORD Management: Proton pump inhibitors (PPIs) for acid suppression, lifestyle changes, and in severe cases, fundoplication surgery.

Complications of Dysphagia

• Aspiration Pneumonia: In patients with oropharyngeal dysphagia, food or liquids can enter the lungs, leading to aspiration and infection.
• Malnutrition and Dehydration: Dysphagia can result in poor oral intake, weight loss, and fluid imbalance.
• Esophageal Stricture: Repeated inflammation or injury from acid reflux can lead to oesophageal narrowing, further worsening dysphagia.

Referral to Specialists

• Gastroenterologist: For suspected oesophageal dysphagia, a referral for endoscopy or motility testing is essential.
• Speech-Language Pathologist: Referral for patients with oropharyngeal dysphagia, particularly if aspiration or neurologic dysfunction is suspected.
• Neurologist: If neurological conditions (e.g., stroke, Parkinson’s) are the suspected cause of dysphagia.
• Surgeon: For patients requiring surgical correction of structural abnormalities, tumours, or severe motility disorders like achalasia.