Dysphagia is a common problem that has the potential to result in severe complications such as malnutrition and aspiration pneumonia. Based on the complexity of swallowing, there may be many different causes. This article presents a systematic literature review to assess different comorbid disease associations with dysphagia based on age. The causes of dysphagia are different depending on age, affecting between 1.7% and 11.3% of the general population. Dysphagia can be a symptom representing disorders pertinent to any specialty of medicine. This review can be used to aid in the diagnosis of patients presenting with the complaint of dysphagia.
Key points
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The causes and associations of dysphagia with different disease states are different among different age groups.
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Dysphagia is increasingly seen by clinicians based on increasing prevalence of gastroesophageal reflux disease, a growing population more than 65 years old, and a longer life expectancy.
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Infancy and early childhood dysphagia are associated with neurodevelopmental delay.
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Childhood through young adult dysphagia is more commonly related to acute infectious processes.
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Dysphagia in middle age is associated with gastroesophageal and immunologic causes.
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The age group older than 60 years is more affected by oncologic and neurologic causes of dysphagia.
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Older age groups have more prominent dysphagia related to stroke, neurodegenerative disease, and dementia.
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Although these generalizations may be of help to the primary assessment of nonsevere dysphagia, neoplastic causes should always be considered.
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A thorough dysphagia assessment should be always be used in the presence of multiple symptoms, severe dysphagia, and failure to respond to initial treatment.
Introduction
Dysphagia is an increasingly common problem, but it is poorly understood by most clinicians. It most commonly affects the elderly population, in which oropharyngeal dysphagia is associated with muscle atrophy, cognitive decline, and increased aspiration risk in as many as 35% of patients older than 75 years. Dysphagia is prevalent in both the unhealthy and the community-dwelling elderly population, with concomitant increased risks for malnutrition and aspiration pneumonia. Although the world population is expected to have 1 billion people older than 65 years by 2020, this number is forecasted to grow to 2 billion by 2050, with a resulting dramatic impact on health care.
| AC | Adenocarcinoma |
| ALS | Amyotrophic lateral sclerosis |
| CI | Confidence interval |
| DES | Diffuse esophageal spasm |
| EE | Eosinophilic esophagitis |
| EGD | Esophagogastroduodenoscopy |
| GEJ | Gastroesophageal junction |
| GERD | Gastroesophageal reflux disease |
| GI | Gastrointestinal |
| HTGM | Heterotopic gastric mucosa |
| MS | Multiple sclerosis |
| NSMD | Nonspecific motility disorder |
| PEG | Percutaneous endoscopic gastrostomy |
| PPI | Proton Pump Inhibitor |
| RR | Relative Risk |
| SCC | Squamous Cell Carcinoma |
| SIR | Standardized incidence ratio |
| SS | Systemic Sclerosis |
| TBI | Traumatic brain injury |
| UES | Upper Esophageal Sphincter |
In addition to the elderly population, a growing awareness of dysphagia in other age groups is appreciated, and associated with a different spectrum of diseases, such as gastroesophageal or laryngopharyngeal reflux. It is therefore imperative that specialists as well as primary care physicians recognize dysphagia, understand likely contributing causes based on age and comorbid diseases, and have the ability to prioritize proper evaluation and treatment plans. However, there is little in the existing literature that connects the causes and associations with dysphagia across all age groups.
Dysphagia may be delineated as mechanical/obstructive causes in young patients, and neurologic/muscular causes in elderly patients. Hoy and colleagues assessed 100 consecutive patients presenting to an outpatient tertiary care swallowing center over a 15-month period. The mean age at presentation was 62 years, and 27% of the identified causes of dysphagia were reflux disease, 14% with postradiation dysphagia, and 11% with cricopharyngeus muscle dysfunction.
Dysphagia in infancy is associated anecdotally with neurodevelopmental delay; in childhood and adolescence it is associated with acute and chronic upper respiratory and tonsil disease; in middle age it is associated predominantly with reflux; and in the elderly it is associated with neurodegenerative disease. We hypothesize that there are different comorbid disease associations with dysphagia based on age, and performed a systematic review of the existing literature to evaluate this hypothesis.
Introduction
Dysphagia is an increasingly common problem, but it is poorly understood by most clinicians. It most commonly affects the elderly population, in which oropharyngeal dysphagia is associated with muscle atrophy, cognitive decline, and increased aspiration risk in as many as 35% of patients older than 75 years. Dysphagia is prevalent in both the unhealthy and the community-dwelling elderly population, with concomitant increased risks for malnutrition and aspiration pneumonia. Although the world population is expected to have 1 billion people older than 65 years by 2020, this number is forecasted to grow to 2 billion by 2050, with a resulting dramatic impact on health care.
| AC | Adenocarcinoma |
| ALS | Amyotrophic lateral sclerosis |
| CI | Confidence interval |
| DES | Diffuse esophageal spasm |
| EE | Eosinophilic esophagitis |
| EGD | Esophagogastroduodenoscopy |
| GEJ | Gastroesophageal junction |
| GERD | Gastroesophageal reflux disease |
| GI | Gastrointestinal |
| HTGM | Heterotopic gastric mucosa |
| MS | Multiple sclerosis |
| NSMD | Nonspecific motility disorder |
| PEG | Percutaneous endoscopic gastrostomy |
| PPI | Proton Pump Inhibitor |
| RR | Relative Risk |
| SCC | Squamous Cell Carcinoma |
| SIR | Standardized incidence ratio |
| SS | Systemic Sclerosis |
| TBI | Traumatic brain injury |
| UES | Upper Esophageal Sphincter |
In addition to the elderly population, a growing awareness of dysphagia in other age groups is appreciated, and associated with a different spectrum of diseases, such as gastroesophageal or laryngopharyngeal reflux. It is therefore imperative that specialists as well as primary care physicians recognize dysphagia, understand likely contributing causes based on age and comorbid diseases, and have the ability to prioritize proper evaluation and treatment plans. However, there is little in the existing literature that connects the causes and associations with dysphagia across all age groups.
Dysphagia may be delineated as mechanical/obstructive causes in young patients, and neurologic/muscular causes in elderly patients. Hoy and colleagues assessed 100 consecutive patients presenting to an outpatient tertiary care swallowing center over a 15-month period. The mean age at presentation was 62 years, and 27% of the identified causes of dysphagia were reflux disease, 14% with postradiation dysphagia, and 11% with cricopharyngeus muscle dysfunction.
Dysphagia in infancy is associated anecdotally with neurodevelopmental delay; in childhood and adolescence it is associated with acute and chronic upper respiratory and tonsil disease; in middle age it is associated predominantly with reflux; and in the elderly it is associated with neurodegenerative disease. We hypothesize that there are different comorbid disease associations with dysphagia based on age, and performed a systematic review of the existing literature to evaluate this hypothesis.
Methods
A literature review of the PubMed database from July 2002 to July 2012 was performed to identify all articles published on the prevalence of dysphagia. Terms for inclusion were dysphagia and related words (dysphagia, odynophagia, globus, deglutition, failure to thrive) linked with an “or” statement, as well as epidemiologic words (prevalence, incidence, etiology, co-morbidity, comorbidity) linked with an “or” statement, and these two searches were linked with an “and” statement. The search only returned articles that satisfied the search criteria based on the content of the title and abstract of the article.
Exclusion criteria were articles published in languages other than English, articles that were published before July 2002, and articles published on the treatment of dysphagia rather than defining prevalence. Review articles permitted identification of additional references for analysis.
Results
The initial search returned 2511 articles. After applying the exclusion criteria, 133 articles remained. An additional 56 articles were identified as pertinent references on analysis of review articles, and added to the 133 articles already identified, combined for a total of 189 articles. This process is shown in the Prisma diagram in Fig. 1 . The population ranged in age from neonates to individuals more than 100 years old, and included a total of 1,013,392 subjects. Fig. 2 is a graph of all the references organized chronologically by the average age of patients studied. It shows that roughly two-thirds of the published literature on dysphagia represents adults older than 50 years.
Prevalence of Dysphagia in the General Population
The reports of dysphagia prevalence vary depending on assessment tool and average age of population studied. Results representative of the general population are summarized in Table 1 . We identified 5 studies that attempted to identify the prevalence of dysphagia through the use of a questionnaire distributed to a random sample of the population. The prevalence ranged from 1.7% to 11.3%, although all of these studies were done in an attempt to identify the prevalence of gastroesophageal reflux disease (GERD) and its associated symptoms. None of these studies were conducted in the United States, and the symptom of dysphagia was more common in the presence of other heartburn-related symptoms. The dysphagia prevalence in elderly adults ranged from 11.4% to 16%, and in unhealthy older patients it was higher at 54% to 55.2%.
| Country | Age of Patients Studied (y) | n | Evaluation Method | Dysphagia Prevalence |
|---|---|---|---|---|
| China | 18–70 | 2789 | Feeling of food stuck in chest or throat >1/mo | 1.7 |
| China | >18 | 2209 | Feeling of food stuck in chest or throat | 3.5 |
| Japan | >40 | 82,894 | Did you suffer from dysphagia in the last month? | 6.9 |
| Australia | >15 | 2973 | Do you have dysphagia rarely or more than rarely? | 10.9 |
| Germany | 20–91 | 268 | Do you have dysphagia? | 11.3 |
| USA | >18 (in doctor’s office) | 947 | Do you have dysphagia several times a month or more? | 22.6 |
| Australia | >18 | 672 | Have you ever had dysphagia? | 16 |
| United Kingdom | >69 (healthy) | 637 | Sydney Oropharyngeal Dysphagia Questionnaire | 11.4 |
| United States | >65 (healthy) | 107 | Do you have difficulties with swallowing? | 15 |
| Netherlands | >87 (mixed health) | 130 | Cough with meals? Food stuck? Food spill? Swallowing more than once to get 1 bite down | 16 |
| Michigan | >60 (unhealthy) | 189 | Clinical examination, fluoroscopic examination, FEES | 54 |
| Spain | >70 (with pneumonia) | 134 | Clinical bedside assessment with water swallow | 55.2 |
Causes of Dysphagia in Different Age Groups
All 189 articles were reviewed and organized based on mean or median age of patients studied. Table 2 shows the different causes of dysphagia separated by the age of patients, and stratified by decade. This table shows that there are distinct causes or associations with dysphagia depending on patient age. The causes of dysphagia in infancy, childhood, and adolescence include congenital causes, acute infectious causes, injury, and neurodevelopmental delay. In the middle-aged population, gastroesophageal and immunologic causes of dysphagia manifest, whereas in the elderly population neurologic and oncologic causes are observed.
| 0–9 y | 10–19 y | 20–29 y | 30–39 y | 40–49 y | 50–59 y | 60–69 y | 70–79 y | 80–89 y |
|---|---|---|---|---|---|---|---|---|
| EE Systemic sclerosis TBI Thyroglossal duct cyst Prematurity Mitochondrial cytopathy Cerebral palsy Cardiac surgery | TBI | Neck infection | EE Inflammatory myopathy MS Thyroglossal duct cyst HTGM | EE Sjögren syndrome HTGM Nasopharyngeal cancer Achalasia Acute supraglottitis MS Cervical dystonia Nutcracker esophagus Lymphocytic Esophagitis Hyperdynamic UES GERD Esophagitis Reflux surgery Mental health disorder Tetraplegia | EE Inflammatory myopathy HTGM Systemic sclerosis Achalasia DES MS NSMD Stroke Lymphocytic esophagus Head and neck cancer GERD Esophagitis Reflux surgery Type 1 diabetes Food impaction Mucositis Cervical spine surgery Cerebral palsy Mental health disorder Radiation Chemoradiation Thyroid disease | Stroke Parkinson disease ALS Lymphocytic esophagitis HTGM Inclusion body myositis Esophageal SCC Anaplastic thyroid cancer Esophageal AC GEJ AC Head and neck cancer Laryngectomy Schatzki ring Alzheimer Zenker diverticulum Cardiac surgery Stricture Cervical spine surgery Frontotemporal dementia Mental health disorder | Stroke Parkinson disease Alzheimer Anaplastic thyroid cancer Achalasia DES Stricture Antipsychotic exposure | Alzheimer Frontotemporal dementia |
Neurologic causes of dysphagia
Most of the epidemiologic dysphagia literature is written on the neurologic causes of dysphagia (61 articles; 10,300 patients). Parkinson disease, stroke, and various causes of dementia are the most frequently published neurologic causes. Some meta-analyses exist that enhanced our systematic review. Alagiakrishnan and colleagues (2012) analyzed 19 articles relating to dementia, and reported a dysphagia prevalence range of 13% to 57%. Kalf and colleagues (2011) performed a meta-analysis of the prevalence of dysphagia in Parkinson disease, identifying 10 articles reporting subjective dysphagia statistics, and determined a pooled prevalence of 35% (95% confidence interval [CI], 28–41). They also reviewed 4 articles reporting objective dysphagia statistics in the Parkinson population, and determined a pooled prevalence of 82% (95% CI, 77–87). Martino and colleagues (2005) summarized 24 articles on dysphagia in patients who had strokes. The reported prevalence of dysphagia was lowest with water swallow screening tests (37%–45%), higher with clinical testing (51%–55%), and highest with instrumental testing (64%–78%), implying that the method of testing affects the reported dysphagia rates. Another stroke review article published by Flowers and colleagues (2011) analyzed 17 articles and stratified dysphagia risk based on stroke location. The incidence of dysphagia according to stroke region was:
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0% in the cerebellum
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6% in the midbrain
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43% in the pons
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40% in the medial medulla
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57% in the lateral medulla
They intended to develop a neuroanatomical model of dysphagia for the brain but were limited to the infratentorial region because of limitations in the quality of the literature.
Performing an analysis of the original articles identified in these review articles, as well as incorporating more recent publications, it is evident that subjective measurements, such as questionnaires, under-report the prevalence of dysphagia compared with more objective measures that incorporate a clinical assessment or an imaging modality. This under-reporting is particularly apparent in the neurodegenerative disease population, such as :
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Parkinson disease (15%–52% subjective, 41%–87% objective)
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Alzheimer disease (7% subjective, 13%–29% objective)
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Frontotemporal dementia (19%–26% subjective, 57% objective)
The enormous variability in dysphagia reporting in patients who have had strokes (25%–81%) is caused by differences in assessment as well as stroke location. Other neurologic diseases commonly associated with dysphagia include :
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Multiple sclerosis (24%–34%)
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ALS (86%)
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Cervical dystonia (2%–36%), and
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Cerebral palsy (6% adult, 99% pediatric)
Table 3 summarizes the causes of dysphagia encountered in this literature review.
| Cause | Qualifier | Dysphagia Prevalence (%) | Average Age (y) |
|---|---|---|---|
| Stroke | — | 25–81 | 56–79 |
| Alzheimer disease | — | 7–29 | 68–79 |
| Parkinson disease | — | 15–87 | 61–75 |
| Frontotemporal dementia | — | 19–57 | 61–80 |
| Multiple sclerosis | — | 24–34 | 34–50 |
| ALS | — | 86 | 65 |
| EE | Pediatric | 21–40 | 6–10 |
| EE | Adult | 33–100 | 34–50 |
| Systemic sclerosis | Pediatric | 39 | 6 |
| Systemic sclerosis | Adult | 74 | 54 |
| Sjögren syndrome | — | 65 | 47 |
| Inflammatory myopathy | — | 18–86 | 34–68 |
| Reflux disease | — | 6–50 | 40–51 |
| Stricture | — | 83 | 65 |
| HTGM | — | 21–39.4 | 37–60 |
| Motility disorder | DES, NSMD, achalasia, etc | 76–94 | 49–71 |
| Zenker diverticulum | — | 86 | 67 |
| Head and neck cancer | Pretreatment | 9.2–67 | 49–64 |
| Head and neck cancer | Posttreatment | 23–100 | 49–64 |
| Esophageal SCC | — | 62–93 | 65 |
| Esophageal AC | — | 53–79 | 63 |
| Anaplastic thyroid cancer | — | 40 | 69 |
| Mucositis | — | 29.10 | 57 |
| Cervical spine surgery | Anterior approach | 0–21.3 | 54–57 |
| Cervical spine surgery | Posterior approach | 0.9–1.87 | 54–61 |
| Reflux surgery | Nissen | 22–52 | 47–58 |
| Reflux surgery | Anterior 90 | 4.8–34 | 47–53 |
| Pediatric cardiac surgery | — | 18–22 | 0–5 |
| Mental health illness | — | 9–42 | 46–68 |
| Neck infection | — | 44 | 25 |
| Supraglottitis | — | 80 | 49 |
| Pediatric head trauma | — | 3.8–5.3 | 6–10 |
| Acute tetraplegia | — | 41 | 49 |
| Thyroglossal duct cyst | Pediatric presentation | 10.60 | 7 |
| Thyroglossal duct cyst | Adult presentation | 20.30 | 36 |
| Thyroid disease | — | 39 | 51 |
Immunologic causes of dysphagia
Thirty-one articles were published on immunologic causes of dysphagia, representing 338,071 patients. Most of these articles (21 of 31) are about EE. Other disease processes that were analyzed include lymphocytic esophagitis (2 articles), inflammatory myopathies (5 articles), systemic sclerosis (2 articles), and Sjögren syndrome (1 article).
Sixteen articles, including 1 review article, were published on EE in the adult population; an additional 5 articles were published on EE in the pediatric population. A review article concluded that the average prevalence of EE in the general population was 0.03%, and 2.8% in the symptomatic population with dysphagia. Ronkainen and colleagues performed esophagogastroduodenoscopy (EGDs) on a randomly selected sample of 1000 people in northern Sweden and diagnosed EE in 0.4%. When retrospectively reviewing esophageal biopsies, investigators in both China and the United States came to similar conclusions, finding evidence of EE in 0.34% to 0.5% of specimens. In studies of EE in patients undergoing endoscopy for any indication, the prevalence ranged from 1.0% to 6.5%. When studying only patients whose indication for endoscopy was dysphagia, EE was even more common, being present in 12% to 15% of patients. Among patients with EE, dysphagia is more common in adults than in children; 70.5 ± 23.7% versus 32.6 ± 8.5% respectively.
Two articles were published on lymphocytic esophagitis, a rare condition (0.09% of all EGD biopsies), but one that is commonly associated with dysphagia (53%–67%). Five articles were written about dysphagia in patients with inflammatory myopathy. The different subsets of inflammatory myopathies seem to have varying prevalences of dysphagia; 65% to 86% in inclusion body myositis, 30% to 60% in polymyositis, and 18% to 20% in dermatomyositis. Mustafa and Dahbour pooled patients with different inflammatory myopathies and reported a combined dysphagia prevalence of 40%. As with most autoimmune processes, episodic flares are common, as suggested by a 94% affirmative response rate to the question, “Have you ever had dysphagia?” Azuma and colleagues showed that patients with inflammatory myopathy have a higher likelihood of developing malignancy (standardized incidence ratio [SIR], 13.8). Gastric cancer was the most common malignancy and merits a full dysphagia work-up in these patients.
Systemic sclerosis is a disease with a bimodal age distribution. In the adult article, 74% of people experienced upper gastrointestinal (GI) symptoms, although it did not specify which symptoms. In the pediatric article, 39% of juvenile patients with SS had dysphagia. Dysphagia in Sjögren syndrome was reported in 65% of patients.
Gastroesophageal causes of dysphagia
Sixteen articles were written on gastroesophageal causes of dysphagia, analyzing 547,156 patients. Although most articles focused on a patient population with 1 specific disease, 2 studies were broader in scope, attempting to diagnose a myriad of patients presenting with the common complaint of dysphagia. When analyzing a national endoscopy database for all patients whose indication for endoscopy was dysphagia, 40.8% of patients had a stricture, 22.1% showed evidence of esophagitis, 13.3% had Schatzki ring, 2.2% had acute food impaction, and 0.9% had malignancy. Tsuboi and colleagues reviewed 24 years of data for all patients undergoing esophageal manometry and 12.1% of patients had nonspecific motility disorder, 6.9% had nutcracker esophagus, 4.6% had diffuse esophageal spasm, and 3.1% had achalasia, whereas most (73.4%) had normal motility.
Reflux and related complications, motility disorders, and HTGM were among the most common gastroesophageal causes of dysphagia published in the recent literature. There were 5 articles written on the prevalence of HTGM. In EGDs conducted for any indication, the diagnosis of HTGM was made in 0.18% to 13.8% of patients (mean, 4.7%). The prevalence of dysphagia was 21.0% to 39.4% and the severity of dysphagia correlated with larger patch size.
Three articles were written on GERD and its related complications such as erosive esophagitis and stricture. In a study that reviewed patients undergoing endoscopy for any reason, the prevalence of reflux esophagitis was 12.3%. In patients with GERD-like symptoms having endoscopy, reflux esophagitis was diagnosed in 22.8%. Dysphagia affects about 37% of patients with GERD, and may be even more prevalent in older adults with GERD. In patients diagnosed with stricture, 83% of them reported symptoms of dysphagia.
There were an additional 3 articles written on motility disorders. Diffuse esophageal spasm was diagnosed in 4% of manometries in one study; however, 76% of those patients complained of dysphagia. Dysphagia was a presenting symptom in 94% of patients who were later diagnosed with achalasia. In a manometry article attempting to determine the cause of globus, a hyperdynamic upper esophageal sphincter was diagnosed in 60% of patients.
Zenker diverticulum is commonly associated with difficulty swallowing, with a reported dysphagia prevalence of 86%. Food impaction in the esophagus is also commonly associated with dysphagia, and one article showed seasonal variation in those cases associated with atopy; impaction was more common in the summer and fall compared with winter and spring.
Congenital causes of dysphagia
Prematurity is the most frequent cause of difficulty feeding in newborns. In a national database review in Taiwan, 50% to 91.7% of low birth weight infants (<2500 g) had feeding problems in their first 5 years of life as measured by need for hospital readmission or outpatient appointment requests for feeding trouble. There are a multitude of factors that contribute to difficulty feeding in low birth weight newborns, but the conclusion of this study was that feeding resources and parent education materials were underused despite the well-established problems experienced by this patient population.
Other causes
There are several other categories that contribute to the long list of possible dysphagia causes. Oncologic, endocrine, psychiatric, infectious disease, surgical complications, injuries, and congenital causes have all been described, and are included in Table 3 . Although it is apparent that oncologic causes of pharyngeal obstruction, and infectious pharyngitis/tonsillitis, result in dysphagia, there was a paucity of literature focusing on these comorbid conditions.
Oncologic
Head and Neck Cancer
This literature contributed 26 articles representing 3165 patients. These studies investigated dysphagia in patients at initial diagnosis as well as long-term dysphagia and percutaneous endoscopic gastrostomy (PEG) tube dependence in patients with varying lengths of follow-up after head and neck cancer treatment with different modalities.
Other Cancers
Other oncologic causes included esophageal, gastric, and lung cancer, and were described in 5 articles representing 2080 patients.
Other possible causes of dysphagia:
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There were 17 articles representing 12,213 patients addressing dysphagia complications from reflux, cardiac, cerebellopontine angle, and cervical spine surgeries.
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Altered mental status from psychiatric illnesses and side effects of neuroleptic medications contribute to dysphagia in this patient population, as described in 8 studies representing 273 patients.
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There were 2 articles representing 481 patients published on infectious causes (deep space neck infections and acute supraglottitis).
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Traumatic brain injuries and tetraplegia are associated with dysphagia as described in 4 articles representing 3069 patients.
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Congenital causes vary from prematurity (the most frequent cause of difficulty feeding in newborns) to thyroglossal duct and laryngeal cysts to mitochondrial cytopathies, as described in 4 articles representing 2275 patients.
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Endocrine causes were outlined in 3 studies representing 360 patients, and described thyroid disease as well as neuropathy from long-standing diabetes mellitus.
Discussion
This review highlights some of the most serious limitations in the dysphagia literature. The definition of dysphagia and the criteria used to make this diagnosis are not widely agreed on. In some studies dysphagia is defined as difficulty swallowing, whereas others describe dysphagia as a specific sensation of food being stuck in the chest. The time course and frequency of symptoms leading to a diagnosis of dysphagia vary depending on author and country of publication. These differences result in significant variability in the reporting of dysphagia prevalence from study to study in patients with the same disease. The instrumentation used to objectively measure dysphagia is also inconsistent. Although some investigators use swallowing speed or swallowing time to identify patients with dysphagia, others use radiographic imaging modalities, others use water swallow tests, and still others use videofluoroscopy. The most common assessment method is the simple question, “Do you have trouble swallowing?” It would be helpful to have a more universal definition of dysphagia, and a reliable assessment method, so that different studies could be compared more directly.
This review shows that most articles concerning dysphagia pertain to neurologic causes. The prevalence of dysphagia in patients with neurodegenerative diseases is very high, which also highlights how many of these patients would not be diagnosed with dysphagia without a formal dysphagia evaluation involving an objective measurement, such as an imaging modality. Asking these patients a simple question about problems swallowing does not capture all of the patients that are having difficulty. A dysphagia screen should be implemented and repeated as a patient’s neurologic disease becomes more advanced. This finding has serious potential implications because there is a significant increased risk of pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07–4.87) and even greater risk of pneumonia in patients with aspiration (RR, 11.56; 95% CI, 3.36–39.77). In contrast, it is unclear when a patient’s dysphagia becomes a health concern. One study diagnosed 22% of older healthy adults with dysphagia based on swallowing speed. This dysphagia is probably not concerning for most of those patients. Perhaps both dysphagia and aspiration scores should be calculated. It may be helpful to evaluate multiple measurements of dysphagia on a longitudinal group of high-risk patients to see which screening modality is the strongest predictor of dysphagia-related complications.
Immunologic and gastroesophageal causes of dysphagia typically affect young, otherwise healthy people. Reflux is a major culprit, but recently EE and HTGM are increasingly recognized as contributors as well. From 1999 to 2009 there was a large increase in the prevalence of EE, from 1.6% to 11.2%, with a concurrent decrease in the prevalence of GERD from 39.3% to 24.1% at a single academic center in the United States. The frequency of biopsy with endoscopy increased over this same time period from 36.7% to 68.7%. EE and HTGM should be considered in addition to other common problems, such as reflux, when an isolated complaint of dysphagia presents in a young, healthy person.
Dysphagia in patients with head and neck cancers after treatment is a serious and persistent complication ( Table 4 ). One of the attractive features of chemoradiotherapy was the possibility of avoiding surgery, and thus offering a patient an organ-preserving therapy. However, there is a large body of evidence to suggest that these treatment protocols do not reduce the prevalence of chronic dysphagia or gastrostomy tube dependence. There are currently no large patient studies comparing dysphagia outcome across the many different treatment modalities. Although the reasons for this are complicated, the dogma that chemoradiation is superior to surgery in terms of preventing dysphagia may not be accurate.
