Overview
This lecture provides a structured approach to evaluating dysphagia (difficulty swallowing), distinguishing between oral/pharyngeal and esophageal causes, their etiologies, diagnostic steps, and key considerations in clinical workup.
Key Terms and Classifications
- Dysphagia is difficulty swallowing and must be distinguished from odynophagia (painful swallowing) and globus sensation (foreign body feeling without obstruction).
- Dysphagia is divided into oral/pharyngeal (difficulty moving food from mouth to esophagus) and esophageal (esophagus to stomach).
Etiologies of Oral/Pharyngeal Dysphagia
- Neurologic: stroke, dementia, Parkinson’s, ALS, MS, brainstem lesions.
- Myopathic: myasthenia gravis, inflammatory myopathies (e.g., polymyositis).
- Other: Zenker’s diverticulum, oral/pharyngeal tumors, xerostomia (dry mouth), mucositis, prior radiation/surgery.
Etiologies of Esophageal Dysphagia
- Intrinsic: food impaction, foreign body (emergencies), GERD/reflux esophagitis, eosinophilic esophagitis, strictures, rings/webs, cancer, infectious esophagitis.
- Extrinsic: mediastinal mass, lymphadenopathy, aortic aneurysm, vascular rings.
- Motility: achalasia, diffuse esophageal spasm, nutcracker esophagus, Chagas disease, systemic sclerosis.
Diagnostic Approach
- History: Type of dysphagia (solids, liquids, or both), onset (abrupt vs gradual), associated symptoms (heartburn, weight loss, cough, speech changes).
- Physical Exam: Oral cavity, lymph nodes, neuro exam (most important), focused abdominal and cardiac exam as indicated.
- Initial Tests:
- Oral/pharyngeal: Video fluoroscopic swallow study, nasopharyngoscopy/FEES.
- Esophageal: EGD (endoscopy), barium swallow, manometry, chest CT.
Diagnostic Algorithm
- Use history to distinguish oral/pharyngeal vs esophageal dysphagia.
- Oral/pharyngeal clues: immediate difficulty, drooling, cough, repeated swallows, neurologic history.
- Esophageal clues: delayed sensation, odynophagia, food stuck in chest, esophageal disease history.
- Dysphagia to solids suggests obstruction; solids and liquids suggest motility disorder.
- EGD is the main initial test for esophageal dysphagia, with alternatives (PPI trial, barium swallow) in select cases.
- Red flags: weight loss, immunocompromised, lymphadenopathy, epigastric mass.
Key Terms & Definitions
- Dysphagia — difficulty swallowing.
- Odynophagia — painful swallowing.
- Globus sensation — feeling of fullness or a lump in the throat without anatomic cause.
- Zenker’s diverticulum — outpouching at the pharyngoesophageal junction.
- EGD — esophagogastroduodenoscopy, endoscopic exam of the esophagus and stomach.
- Manometry — test to measure pressures/motility in the esophagus.
Action Items / Next Steps
- Review causes and diagnostic algorithms of dysphagia.
- Know the indications for key tests: video swallow, EGD, manometry.
- Study physical exam findings and red flag symptoms.
- Prepare for case-based problem-solving involving dysphagia evaluation.