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Dysphagia (swallowing problems)


Introduction

Dysphagia refers to difficulty in swallowing solids, liquids, or both. It is a common complaint, especially in the elderly, and may significantly impair nutrition, hydration, and quality of life. In some cases, it indicates life-threatening diseases such as stroke, neuromuscular disease, or esophageal carcinoma.

It is essential to differentiate between:

  • Oropharyngeal dysphagia: Difficulty initiating swallow, coughing, aspiration.

  • Esophageal dysphagia: Sensation of food sticking or delayed passage down the esophagus.

Physiology of Swallowing

Swallowing occurs in three coordinated phases:

  1. Oral phase (voluntary): Mastication and propulsion of bolus to oropharynx.

  2. Pharyngeal phase (involuntary): Soft palate elevates, epiglottis covers airway, pharyngeal muscles contract.

  3. Esophageal phase (involuntary): Peristaltic waves carry bolus into stomach; lower esophageal sphincter relaxes.

Disruption in any phase may cause dysphagia.

Causes of Dysphagia

1. Oropharyngeal Dysphagia (Neurological/Muscular)

  • Stroke (CVA): Commonest cause in adults.

  • Parkinson’s disease.

  • Motor neuron disease (ALS).

  • Multiple sclerosis.

  • Myasthenia gravis.

  • Muscular dystrophies.

  • Structural causes: Zenker’s diverticulum, pharyngeal tumors, enlarged thyroid.

2. Esophageal Dysphagia

a. Mechanical Obstruction

  • Esophageal cancer.

  • Peptic stricture (due to GERD).

  • Schatzki ring.

  • Eosinophilic esophagitis.

  • Foreign body.

b. Motility Disorders

  • Achalasia (failure of lower esophageal sphincter to relax).

  • Diffuse esophageal spasm.

  • Scleroderma (hypomotility due to fibrosis).

c. Inflammatory/Infective

  • Reflux esophagitis (GERD).

  • Infective esophagitis (Candida, HSV, CMV).

  • Caustic ingestion (corrosives).

Clinical Presentation

  • Oropharyngeal dysphagia: Difficulty initiating swallow, nasal regurgitation, coughing, choking, aspiration, recurrent pneumonia.

  • Esophageal dysphagia: Food “sticks” after swallowing, sensation behind sternum, may affect solids first then liquids (mechanical obstruction) or both (motility disorder).

  • Associated symptoms:

    • Weight loss: Malignancy, severe obstruction.

    • Odynophagia (painful swallowing): Infection, ulcer, severe esophagitis.

    • Heartburn/regurgitation: GERD.

    • Neurological deficits: Stroke, neuromuscular disease.

Diagnostic Approach

1. History

  • Solids vs liquids, progressive vs intermittent.

  • Associated chest pain, heartburn, regurgitation, coughing.

  • Neurological symptoms.

  • Risk factors (smoking, alcohol, caustic ingestion).

2. Physical Examination

  • Oral cavity, dentition, tongue mobility.

  • Cranial nerve assessment.

  • Neurological examination.

  • Signs of malnutrition or dehydration.

3. Investigations

  • Barium swallow (esophagogram): Shows structural/motility disorders.

  • Upper endoscopy (EGD): Direct visualization, biopsy for malignancy/inflammation.

  • Esophageal manometry: Gold standard for motility disorders (achalasia, spasm).

  • Videofluoroscopic swallowing study: Oropharyngeal dysphagia assessment.

  • Blood tests: CBC, electrolytes, thyroid function.

Management and Treatment

Treatment is tailored to the cause.

A. General Supportive Measures

  • Dietary modifications: soft or pureed foods, thickened liquids.

  • Swallowing therapy (speech-language pathologist).

  • Postural changes: chin-tuck technique for aspiration prevention.

  • Nutritional support: nasogastric feeding or PEG tube if severe.

B. Oropharyngeal Dysphagia

1. Stroke-related Dysphagia

  • Swallowing rehabilitation exercises.

  • Thickened fluids to prevent aspiration.

  • Feeding tube if unsafe swallowing persists.

2. Neuromuscular Disorders

  • Myasthenia gravis:

    • Pyridostigmine: 60 mg orally every 4–6 h.

    • Immunosuppressants (prednisone 10–60 mg daily, azathioprine 1–3 mg/kg daily).

  • Parkinson’s disease:

    • Levodopa/carbidopa: Individualized dosing, often 100/25 mg orally 3–4 times daily.

    • Speech and swallow therapy.

3. Zenker’s Diverticulum

  • Surgical/endoscopic diverticulectomy.

C. Esophageal Dysphagia

1. Mechanical Obstruction

  • Esophageal cancer: Surgery, radiotherapy, chemotherapy; palliative stenting.

  • Peptic stricture (GERD-related): Endoscopic dilation + acid suppression.

    • Omeprazole: 20–40 mg orally once or twice daily.

  • Eosinophilic esophagitis:

    • Swallowed topical corticosteroids (fluticasone 440–880 mcg/day or budesonide 1–2 mg/day).

    • Elimination diet.

  • Schatzki ring: Endoscopic dilation.

2. Motility Disorders

  • Achalasia:

    • Pneumatic dilation, Heller myotomy, or POEM (endoscopic myotomy).

    • Nifedipine 10–30 mg orally before meals or Isosorbide dinitrate 5 mg sublingual before meals for temporary relief.

  • Diffuse esophageal spasm:

    • Calcium channel blockers (diltiazem 30–60 mg orally three times daily).

    • Nitrates: Isosorbide dinitrate 5 mg sublingual.

    • Botox injection into LES in refractory cases.

3. Inflammatory/Infective

  • GERD:

    • Lifestyle: weight loss, avoid alcohol, spicy food, late meals.

    • PPIs (omeprazole 20–40 mg orally daily, lansoprazole 30 mg daily).

  • Candida esophagitis:

    • Fluconazole 200 mg orally loading, then 100–200 mg daily for 14–21 days.

  • Herpes esophagitis:

    • Acyclovir 400 mg orally five times daily for 14–21 days.

  • CMV esophagitis:

    • Ganciclovir 5 mg/kg IV every 12 h for 14–21 days.

D. Retrograde and Aspiration Management

  • In high-risk aspiration: speech therapy, diet modification, PEG tube.

  • Antibiotics if aspiration pneumonia develops:

    • Amoxicillin–clavulanate 875/125 mg orally twice daily for 7–10 days.

Complications

  • Malnutrition, dehydration, weight loss.

  • Aspiration pneumonia.

  • Strictures or fistulas.

  • Underlying malignancy progression.

Prognosis

  • Stroke-related dysphagia: Many recover within weeks to months, though some remain chronic.

  • GERD-related strictures: Good prognosis with dilation and PPI therapy.

  • Achalasia: Treatable with surgery/endoscopy; lifelong follow-up needed.

  • Esophageal cancer: Prognosis depends on stage; often poor if diagnosed late.

Patient Education

  • Chew food thoroughly, eat slowly.

  • Modify diet (soft foods, thickened liquids).

  • Sit upright while eating; remain upright after meals.

  • Avoid alcohol, smoking, reflux-inducing foods if GERD.

  • Report red-flag symptoms: weight loss, progressive dysphagia, hematemesis.



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