Definition
A.Dysphagia is defined as difficulty swallowing.
1.Oropharyngeal dysphagia is defined as difficulty with the initial task of swallowing, which can be accompanied by choking, coughing, or a food block in the pharynx.
2.Esophageal dysphagia is defined as difficulty swallowing after the initiation of swallowing; feeling food lodged in the esophagus. A motor disorder occurs when there is difficulty swallowing solids and/or liquids. This can be intermittent or progressive. A mechanical obstruction occurs when there is difficulty swallowing solids, which may be nonprogressive or progressive:
a.Nonprogressive disorders include an esophageal ring or eosinophilic esophagitis.
b.Examples of progressive disorders include peptic stricture (chronic heartburn is present) and esophageal/gastric cardia cancer.
3.Odynophagia is defined as having pain with swallowing.
Incidence
A.Dysphagia affects approximately 300,000 to 600,000 persons annually.
B.Approximately 15% of the elderly population is affected by dysphagia.
Pathogenesis
A.In advancing age, muscle strength and the range of motion of swallowing decline, which may impact the effectiveness of swallowing. A decrease in oral secretions, taste changes, and smell acuity may also impact the effectiveness of swallowing.
Predisposing Factors
A.Age (elderly).
B.Neurologic conditions such as stroke, myasthenia, multiple sclerosis, Parkinson’s disease, and so on.
C.Dementia.
D.Trauma or radiation to neck and head.
Common Complaints
A.Difficulty with swallowing.
B.Reflux of food/liquid into the nose.
Other Signs and Symptoms
A.Weight loss.
B.Nutritional deficiency.
C.Refusal to eat.
Potential Complications
A.Malnutrition.
B.Pneumonia.
Subjective Data
A.Ask the patient if he or she has difficulty swallowing when initiating the swallow or a few seconds after trying to swallow.
B.Does difficulty swallowing occur at every meal or snack? If so, is it getting worse?
C.Is it difficult to swallow solid foods, liquids, or both? Difficulty swallowing solids and liquids occurs when a motility disorder of the esophagus is present. Difficulty swallowing solids that generally progresses to liquids is commonly caused by a mechanical obstruction.
D.When swallowing occurs, does the patient experience coughing or reflux, or does food go up through the nose?
E.Can the patient identify a site where food commonly gets lodged?
F.Has the patient noticed any change in appetite? Weight loss or weight gain? Nausea, vomiting, diarrhea, constipation, change in stools, heartburn, or chest pain?
G.Has the patient started any new medications that have caused indigestion or reflux?
1.Common medications that may cause reflux include bisphosphonates, ferrous sulfate, potassium chloride, ascorbic acid, tetracycline, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Physical Examination
A.Vital signs: Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Inspect the oral cavity for lesions, ulcers, and poor dentition. Note muscle weakness or paralysis in movement of tongue.
2.Inspect head and neck for any masses.
3.Inspect face for muscle weakness and neck for swallowing difficulty.
4.Assess all cranial nerves, focusing on cranial nerves V, VII, X, XI, and XII.
C.Palpate:
1.Palpate the neck and supraclavicular lymph nodes for adenopathy or palpable masses.
D.Auscultate:
1.Heart.
2.Lungs.
Diagnostic Tests
A.Upper endoscopy.
B.Barium swallow.
C.Motility testing.
Differential Diagnosis
A.Oropharyngeal dysphagia.
B.Esophageal dysphagia.
C.Odynophagia.
D.Achalasia (decreased peristalsis in the distal esophagus and loss of relaxation of the lower esophageal sphincter while swallowing).
Plan
A.General interventions: Identify the cause of dysphagia and treat accordingly.
B.Patient teaching:
1.Educate the patient regarding the possible causes of dysphagia.
2.Stress the importance of nutrition and educate the patient and family about dietary alternatives to maintain nutrition and prevent weight loss.
3.Discuss potential diagnostic testing necessary to identify the cause of dysphagia.
C.Dietary management:
1.Depending on the diagnosis and treatment, dietary management—solids versus liquids—will need to be discussed with the patient and family.
2.A modified food diet should be provided for the patient and family, prepared with a nutritionist and dietitian.
D.Pharmaceutical therapy:
1.H2 blockers and proton pump inhibitors may be prescribed to help control acid reflux.
2.If infection of the esophagus is suspected, antibiotics may be considered.
3.Calcium channel blockers may help with esophageal spasms.
Follow-Up/Referral
A.Refer to gastroenterology for screening tests required for diagnosis.
B.Refer to a speech or swallowing specialist for assessment and education regarding swallowing exercises.
C.Refer to a dietitian/nutritionist for alternative food options and education on proper nutrition and prevention of weight loss.
Individual Considerations
A.Geriatrics:
1.Dysphagia may occur in conditions such as systemic sclerosis and Sjögren’s syndrome.
2.Dysphagia is commonly seen after long-term intubation.
3.For the elderly population, consider cancer in the differential diagnosis if the patient is noted to have anemia and/or weight loss.
4.Neurological origin is the most common cause for oropharyngeal dysphagia and can be efficiently managed by the provider in collaboration with a clinical swallow specialist.
5.Screen all geriatric patients for dysphagia because the swallowing reflex is regarded as a normal age-related occurrence. Any difficulties would render further studies as well as initiate education for diet and mechanical exercises to prevent aspiration and other complications.
6.Recommend safe swallowing techniques to geriatrics patients, which could include multiple small swallows, chin-tuck when swallowing, dietary modifications, avoiding rushed/forced eating, sitting upright 90 degrees, and a review of safe administration of medications and practices that are unsafe (such as crushing enteric-coated tablets).
7.Speech therapist or clinical swallow specialist would manage any food consistency changes unique to patient’s needs and degree of swallowing challenges.