Fig. 3.1
Algorithm for clinical diagnosis of dysphagia
4.
Associated symptoms: Does patient cough or get chest pain associated with dysphagia? Dysphagia (for solids and liquids) with chest pain and regurgitation are the cardinal symptoms of esophageal motility disorders [4]. Regurgitation with foul smell is an indication of a pharyngeal diverticulum. In regurgitation associated with esophageal dysmotility, there is no foul smell.
Chest pain is associated with diffuse esophageal spasm or achalasia. It can be difficult to distinguish this “crushing” type of chest from that of the typical “heartburn” of reflux [5]. This pain often occurs during meals but can also be nocturnal and sporadic. Chest pain is often a prominent symptom in patients with early achalasia but decreases over the years as dysphagia and regurgitation worsen [6]. On the other hand, chest pain associated with esophageal spasm is severe and predominant, but regurgitation is not a prominent symptom.
Dysphagia in a scleroderma patient suggests a stricture as they mainly have reflux and regurgitation in the early stages.
If the bolus is obstructed at the cricopharyngeal sphincter level, then the patient could have coughing due to aspiration.
Pain associated with swallowing is called odynophagia. It may be due to oropharyngeal ulcers, tonsillopharyngitis, inflammation of the lingual tonsils, or even arytenoid inflammation.
Globus pharyngis is a sensation of either phlegm or something being stuck in the throat although no obstruction is actually found. These patients may develop the habit of continuously clearing their throat. They can swallow normally, and hence globus is not true dysphagia. Globus could be either psychogenic or due to inflammation of pharyngeal or laryngeal mucosa or gastroesophageal reflux.
5.
How is dysphagia relieved? Does the patient drink water to relieve dysphagia? Sipping water often relieves dysphagia due to the bolus being held by a structural obstruction.
6.
Associated history of medication intake: Prolonged use of proton pump inhibitors could suggest gastroesophageal reflux with Barrett’s esophagus associated history of surgery/intubation – could suggest intubation trauma to soft palate, post pharyngeal wall, arytenoids, or postintubation pharyngeal or arytenoid edema causing dysphagia.
Physical Examination
General Examination
Age: Young children may routinely have a certain amount of aspiration. However, the quantities are small and relatively quickly cleared from the lungs due to normal lung physiology and the normal immunological mechanisms especially as children are active and mobile. Persons over age 60 may have age-related changes in sensory discrimination of the tongue with reduced sensitivity (on tests of two-point discrimination) in the anterior two thirds of the tongue compared to people under 40 years [7]. Age-related changes in tongue motor function lead to prolonged oral transit time in individuals over 60 years of age when compared to people less than 60 [8]. An elderly patient complaining of a sensation of food (solids or liquids) sticking in his lower chest area with slight weight loss is likely to have achalasia. A middle-aged man with occasional dysphagia, who otherwise feels well and whose esophageal motility studies show an LES amplitude of approximately 60 mmHg and his esophagus relaxes completely when he swallows, is most likely to have hypertensive LES.
Appearance: Cachexia in a patient with dysphagia could signify inadequate nutrition and therefore significant obstruction or immunocompromise.
Immunocompromised patients have a reduced ability to fend off infection from normal or dysphagic aspiration. For other patients, the disease process may specifically affect the swallowing function.
Neurological:
Testing cranial nerves V, VII, IX, X, and XII and evaluating movements of the mandible, muscles of mastication, facial muscles, tongue, and palate along with an assessment of the mass, strength, symmetry, and range of movement of the muscles. Facial nerve palsy can affect lip movements, leading to dribbling and therefore affecting the oral phase of swallowing.
Cough reflex. Loss of the cough reflex indicates decreased airway clearance, and these patients may have dysphonia with a “wet” or “bubbling” voice.
Complete neurological examination: Evaluating for cerebellar lesions (Wallenberg’s syndrome), amyotrophic lateral sclerosis, etc.
Cervical movement: It is imperative to check cervical movements in elderly patients with dysphagia. Radiological examination (plain X-ray neck lateral view or computed tomography scan) may show excess bone growths or osteophytes from the anterior part of the cervical spine impinging on the pharynx or esophagus leading to dysphagia (Fig. 3.2). Degenerative changes of the spine lead to formation of osteophytes. Occasionally, the condition may be a part of a disorder called diffuse idiopathic skeletal hyperostosis. Treatment can vary from observation to surgical removal of the osteophytes depending upon the severity of the symptoms.
Fig. 3.2
Cervical osteophytes (arrow) impinging on pharyngolaryngeal lumen
Local Examination
Inspection of the oral cavity should include a thorough dental evaluation.
Edentulousness (Fig. 3.3) alone constitutes oral dysphagia and risks boluses being too large or coarse for proper passage through the pharynx. Poorly fitting dentures or a missing denture could suggest foreign body aspiration leading to obstruction. Other oral pathologies associated with oral dysphagia include mucositis (aphthous ulcers, herpes, etc.) (Fig. 3.4), reduced salivation (Sjögren syndrome, antihistamines, anticholinergic drugs, etc.), or intraoral tumors (Fig. 3.5).
Fig. 3.3
Edentulous patient
Fig. 3.4
Oral candidiasis
