Odynophagia

Jeremy D. Richmon and James Rocco

The term odynophagia derives from the Greek roots odyno – (pain) and – phagein (to eat) and refers to the symptom of painful swallowing. This is different from dysphagia, which refers to difficulty swallowing. Although both symptoms are often present together they each may present separately as well and should not be confused. Odynophagia is a broad term that may refer to a myriad of symptoms and disease processes. The key distinguishing characteristic in odynophagia is onset (sudden or immediate, rapid, or slowly progressive). Other important aspects of the history include duration (hours, days, months, or years), clinical course (progressive, resolving, constant, or fluctuating), severity (mild vs severe), location (oropharyngeal or retrosternal), and exacerbating factors such as immunosuppression or other systemic diseases. The differential diagnosis of odynophagia is vast (Table 47.1). Therefore, the most critical element in patient evaluation is a thorough and directed history to narrow the differential diagnosis. After a thorough history, a complete head and neck examination including indirect laryngoscopy (unless epiglottitis is suspected in a pediatric patient) should further limit the differential of odynophagia.

Sudden or immediate-onset odynophagia is usually caused by an iatrogenic or traumatic etiology. The presentation of symptoms can usually be related to a particular circumstance, such as having finished a meal, taking a specific medicine, or experiencing trauma or a trip to the operating room.

Iatrogenic: A recent history of upper aerodigestive tract manipulation followed by odynophagia should lead one to suspect a mucosal tear, muscular injury, and perforation, with mediastinitis being the most feared complication. Although odynophagia is common after intubation as a result of mild mucosal trauma and inflammation from the endotracheal tube, one must suspect more serious injury if pain is not resolving by postoperative day 2, is worsening, or is accompanied by systemic signs/symptoms such as leukocytosis, fever, tachycardia, chest pain, dysphagia, and sepsis. Traumatic esophagitis can also occur after nasogastric tube placement or after esophageal or gastric suctioning.

Arytenoid subluxation: Malpositioning of the arytenoid cartilage. It is usually the result of upper airway instrumentation (postintubation), although it can result from external trauma to the neck. It typically presents with hoarseness along with dysphagia, odynophagia, and cough. Diagnosis can be established by the clinical timing, laryngoscopy, and computed tomography (CT) of the larynx with spiral CT.

Traumatic: Similarly, odynophagia associated with a recent history of trauma should result in a thorough evaluation to distinguish between simple muscular strain and more serious vascular, cervical, esophageal, or laryngeal injury.

**Table 47.1** Causes of Odynophagia
Vascular	Carotidynia
Infectious	Tonsillitis/adenoiditis/pharyngitis Esophagitis Epiglottitis/supraglottitis
Iatrogenic	Aerodigestive tract manipulation/perforation, arytenoid subluxation
Inflammatory	Eosinophilic esophagitis Gastroesophageal reflux Laryngopharyngeal reflux Eagle syndrome
Neoplastic	Malignancy of oropharynx, hypopharynx, larynx, esophagus (squamous cell, adenoid cystic, adenocarcinoma, lymphoma, sarcoma)
Drugs/toxins	Caustic ingestion Pill esophagitis Mucositis secondary to chemotherapy or radiotherapy
Autoimmune	Scleroderma Systemic sclerosis Mixed connective tissue disease Polymyositis/dermatomyositis Crohn disease Pemphigoid/Stevens-Johnson syndrome/pemphigus Rheumatoid arthritis
Trauma	Blunt (tear, hematoma) Penetrating (laceration or perforation) Whiplash Foreign body (fish or chicken bone, food impaction, coin, toy, battery)
Other	Rings/webs/stricture Esophageal motor disorders (achalasia and diffuse esophageal spasm) Plummer-Vinson syndrome Eagle syndrome

Caustic ingestion: Ingested chemicals either by accident (children) or in suicide attempts (adults) can result in mucosal injury depending on the type, concentration, and volume of the ingested substance. Household and garden materials are usually alkalis and cause a deep liquefaction necrosis with fat and protein digestion. Acids are less frequently encountered and typically lead to a more superficial coagulation necrosis with eschar formation. Complications include hematemesis, perforation, peritonitis, mediastinitis, and late-developing stricture.

Foreign body ingestion: In this setting, odynophagia often indicates a sharp object that has penetrated the oropharyngeal mucosa, typically fish or chicken bones, toothpicks, needles, and dental bridgework. Blunt foreign body ingestions, on the other hand, often present with dysphagia or complete obstruction. Because many foreign bodies are radiolucent, endoscopy is required when imaging studies fail to reveal an etiology. Three narrow areas of the digestive tract tend to trap foreign bodies: (1) the cricopharyngeus muscle, (2) the middle third of the esophagus, and (3) the lower esophageal sphincter.