Dysphagia and odynophagia

I. Problem/Condition.

Dysphagia is the sensation of having difficulty swallowing. This can range from difficulty with deglutition (the coordinated, active process of passing food and liquids from the oral cavity into the oropharynx and below) to the passive passage of contents from the oropharynx through the esophagus and into the stomach. Odynophagia, which is often confused with dysphagia, is pain with swallowing. Both of these symptoms indicate an abnormality—either benign or malignant—that should be further worked up and evaluated.

It is important to distinguish between dysphagia and globus sensation or hyposalivation as they have different differential diagnoses and evaluation algorithims. Globus is the feeling of having a “lump in the throat” while normal swallowing is preserved. As opposed to dysphagia, it is often present between meals and improves with eating.

II. Diagnostic Approach

A. What is the differential diagnosis for this problem?

Oropharyngeal dysphagia

Neurological:

Stroke (or other neurological insult to the brain stem including tumors, trauma, etc.)

Parkinson’s disease

Multiple sclerosis

Cerebral palsy

Dementia

Guillain-Barré syndrome

Huntington’s disease

Amyotrophic lateral sclerosis

Tardive dyskinesia

Polio

Myopathic:

Myasthenia gravis

Connective tissue disease (overlap syndrome)

Myotonic dystrophy

Oculopharyngeal dystrophy

Sarcoidosis

Paraneoplastic syndromes

Dermatomyositis

Structural:

Cricopharyngeal bar

Zenker’s diverticulum (delayed regurgitation of undigested food)

Cervical webs

Oropharyngeal tumors

Congenital (cleft palate, diverticula, pouches, etc.)

Metabolic:

Amyloidosis

Cushing’s syndrome

Thyrotoxicosis

Wilson’s disease

Infectious:

Diphtheria

Botulism

Lyme disease

Syphilis

Mucositis (Candida, herpes simplex virus [HSV], cytomegalovirus [CMV], etc.)

Iatrogenic:

Medication side effect (pill esophagitis, radiation)

Postsurgical

Corrosive (caustic ingestion)

Esophageal dysphagia

Initial symptoms only to solids—think of lesions that are stable in size:

Esophageal webs or rings

Radiation injury (can cause strictures, ulcerations with odynophagia)

Left atrial enlargement

Vascular abnormalities compressing the esophagus

Initial symptoms to solids and liquids—think of motility and mucosal disorders:

Esophagitis (Candida, CMV, HSV, eosinophillic [progressive])

Achalasia

Scleroderma

Nutcracker esophagus

Diffuse esophageal spasm (can have chest pains as well)

Non-specific esophageal disorder

Initial symptoms start with solids, but progress to involve both solids and liquids—think of lesions that get bigger or tighter with time:

Malignancy

Peptic stricture

Functional dysphagia

A diagnosis of exclusion when no other etiology is identified.

B. Describe a diagnostic approach/method to the patient with this problem

The broad symptoms of dysphagia can be broken down into two main classifications: oropharyngeal dysphagia and esophageal dysphagia.

Oropharyngeal dysphagia involves deglutition, which is a complex process requiring the coordinated action of many muscles simultaneously. Not surprisingly, disorders leading to the oropharyngeal dysphagia tend to be neuromuscular in origin and cause abnormalities from the mouth to the upper esophagus. Patients usually describe difficulty with initiating swallowing or feeling food get stuck shortly after initiating swallowing, and localize the symptoms to the throat or cervical area. They may also complain of coughing or choking with eating.

Esophageal dysphagia is usually caused by anatomical or motility disorders of the esophagus and occasionally the gastric cardia. Patients usually describe symptoms of food getting stuck several seconds after initiating swallowing and identify it occurring at or below the sternal notch.

1. Historical information important in the diagnosis of this problem.

As always, history is very important in identifying the etiology of dysphagia. The first step is to distinguish oropharyngeal from esophageal dysphagia. In the former, patients describe the onset of symptoms with or shortly after the initiation of swallowing. In esophageal dysphagia, patients will report having symptoms that are delayed several seconds after the initiation of swallowing. When asked to localize their symptoms, oropharyngeal dysphagia patients will often point to their throat or cervical area, while patients with esophageal dysphagia will often point to their sternal notch or retrosternal area. It is important to note, however, that in 15-30% of cases of distal esophageal obstruction, patients will subjectively localize their symptoms to the sternal notch. Therefore, patients’ subjective localization of discomfort is not necessarily reliable for distinguishing between oropharyngeal and esophageal dysphagia.

These are questions to ask patients when evaluating dysphagia.

When did you first start to notice difficulty swallowing and was it temporally associated to any other event (such as trauma, illness, stroke)?
Do you have problems when you first start to swallow or does it begin several seconds after you try to swallow your food?
Do you ever cough, choke, or regurgitate food when you try to swallow?
Do you have problems with your mouth feeling excessively dry? (This can potentially indicate hyposalivation instead of dysphagia.)
Do you have pain with swallowing?
Where do you feel the food getting stuck? (If they describe food getting stuck in the throat, ask if they have this feeling when they are eating, i.e. after swallowing, or is it more during periods of time between eating. The latter is more suggestive of globus and not dysphagia.)

The next distinctions to make are 1) what type of foods illicit the symptoms (solids, liquids, or both), and 2) whether the symptoms are constant, intermittent, or progressive.

When you first started having problems with swallowing, did you notice the symptoms mainly with solid foods, liquids, or both?

If the patient says both, ask “do you recall if you started having symptoms with both solids and liquids, or did you initially notice symptoms only with solid foods and it then progressed to both solids and liquids?” Sometimes to help jog people’s memory, you can give examples of solids such as “meat or bread.” Often people will say most solids are fine, but when you ask about meat or bread they will admit they don’t eat these foods because of previous difficulty swallowing.

Have you noticed that your symptoms are getting worse or have they stayed the same? Do the symptoms come and go or do they occur every time you swallow?

Progressive symptoms are concerning for malignancy, peptic strictures, or progressive motility disorders such as scleroderma. Intermittent or constant symptoms are more suggestive of benign processes such as esophageal rings/webs.

Asking a pertinent past medical history as well as questions to determine severity of the disorder can also help narrow your potential diagnoses.

Have you noticed any other symptoms such as weight loss, loss of appetite, nausea, vomiting (bloody or non-bloody), diarrhea (bloody or non-bloody), heartburn, chest pain, or regurgitation of food?
Do you have any other medical illnesses such as diabetes, history of stroke, Parkinson’s disease, myasthenia gravis, multiple sclerosis, muscular dystrophy, scleroderma, Sjögren’s disease, or cancer?
Do you smoke or drink alcohol (risk factors for esophageal and throat cancer)?
Have you ever had surgery or radiation therapy to your head, neck, or chest?
Do you take any medications? Specifically ask about medications that are known to cause pill esophagitis: potassium, doxycycline, ferrous sulfate, bisphosphonates, quinidine, ascorbic acid, or anti-inflammatory medications such as acetylsalicylic acid (ASA) and non-steroidal anti-inflammatory drugs (NSAIDS).

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

When examining a patient with dysphagia, visually inspect the oral cavity (look for ulcerations, thrush, mass) and palpate for lymphadenopathy, masses, or goiter. General appearance and other systemic disease findings should be noted through a complete neurological exam, constitution (looking for obvious signs of weight loss, malnutrition), raspy or gurgly voice (possible evidence of gastroesophageal reflux disease [GERD] and/or aspiration), respiratory exam (signs of aspiration), cardiac exam for heart failure (atrial dilation can cause dysphagia), skin and extremity exam for signs of scleroderma or Sjögren’s disease.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Five tests are useful: barium swallow, modified barium swallow with speech therapy, nasopharyngeal laryngoscopy, upper endoscopy, and manometry.

Barium swallow evaluates for anatomical and motility abnormalities.

Modified barium swallow with speech therapy includes videofluoroscopy and specific evaluation of swallowing. It is useful for neuromuscular disorders and, when there is a concern for aspiration, it can be focused more on oropharyngeal dysphagia.

Nasopharyngeal laryngoscopy with or without fiberoptic endoscopic evaluation of swallowing (FEES) is performed by an otolaryngologist. Visualization of the oropharynx, hypopharynx, and larynx is achieved while the patient is asked to swallow food and liquid boluses dyed with food coloring for easy recognition. The physician can then check directly for presence of foreign material in the larynx or regurgitating back up from the esophagus. It also allows the operator to check for sensation of the larynx since decreased sensation from a stroke, for example, could lead to significant aspiration.

Upper endoscopy allows direct visualization of the oral cavity, oropharynx, hypoharynx, and esophagus down to the stomach. It can be used simultaneously for treatment as well as diagnosis, including brushings and biopsy if indicated. An ultrasound tip can also be used for endoscopic evaluation.

Manometry can help evaluate for abnormal pressures throughout the food consumption process.

III. Management while the Diagnostic Process is Proceeding

A. Management of dysphagia and odynophagia

Much of the workup for dysphagia can be done as an outpatient. However, there are several important things that should be considered and worked up as an inpatient.

Does the patient have acute dysphagia?
Is the patient an aspiration risk?
Does the patient have a progressive unrecognized malignancy?
Did the patient have an acute neurological insult manifesting as dysphagia?
Does the patient have an acute infection that a) needs to be treated and b) needs to be worked up in terms of related immunosuppressed states?
What is the patient’s current nutritional status and short-term nutrition risk?

Many of these clinical questions can be evaluated with a thorough patient history. Keep in mind that you will often need to ask questions of family members or other caregivers (if available) to get a complete history.

Acute dysphagia

In patients with acute dysphagia (onset 1-2 days), the immediate things that should be considered and worked up are mechanical obstruction, acute neurological insult, or medication related esophagitis. The first two are discussed in the section on neurological insult below. Medication-related esophagitis can be due to antibiotics such as tetracyclines, NSAIDs such as aspirin, and other non-enteric coated anti-inflammatory medications as well as various other medications such as potassium chloride, bisphosphonates and quinidine. It often presents with acute onset odynophagia and chest pain—often retrosternal. Diagnosis can often be made clinically with the appropriate history of a pill ingestion. However, if it is not clear or if the symptoms are severe, upper endoscopy can be performed.

Aspiration risk

To help determine if the patient is an aspiration risk, you can ask questions about how the patient is eating. Are they coughing or choking with food intake (solids, liquids, or both)? Look at their past medical history: have they had any strokes or have any neurological disorder? An acute neurological insult is also possible: what is the time course of the patient’s symptoms? Are there any other neurological deficits? Along with history, you need to do a physical exam and assessment, much of which will consist of general observations in terms of the patient’s strength, speech, muscle control, etc.

If you suspect the patient is an aspiration risk, it is best to make them nil per os (NPO) until they can be evaluated by a speech therapist or with a modified barium swallow. Based on the results of these tests and evaluations, you can either resume the patient’s per os (PO) diet or perform further workup as indicated.

Malignancy

Certain historical symptoms are more suggestive of dysphagia due to malignancy. This includes unintentional weight loss, anorexia, family history of cancer, history of alcohol and/or tobacco use, and rapid progression of dysphagia symptoms. Patients often initially experience dysphagia with solid foods and then progress to include liquids as the lesion grows. Patients may also complain of chest pain and odynophagia with oral intake. When malignancy is suspected, a barium swallow (usually with video fluoroscopy) is conducted to look for lesions. Occasionally, a computed tomography (CT) chest scan may also be needed to better characterize extra-esophageal lesions.

Acute neurological insult

Depending on the time course of the patient’s symptoms, dysphagia could be a manifestation of an acute neurological insult such as a stroke or transient ischemic attack (TIA). It is important to ascertain when the symptoms began. Was it acute or subacute in onset? Are there any other neurological symptoms to suggest a stroke or TIA? For new dysphagia, particularly if acute in onset, a thorough neurological exam should be conducted, and if there is any concern for an acute neurological insult, central nervous imaging (CNS) imaging should be obtained and neurology consult should be considered.

Of note, acute dysphagia can also be due to a mechanical obstruction (food bolus) of meat or other thick/dense foods and needs to be evaluated immediately. This may require mechanical removal or passage of the food via endoscopy.

Acute infection

Infectious esophagitis is almost always seen in immunocompromised patients with acquired immune deficiency syndrome (AIDS), malignancy, or use of immunosuppressive medications. There have, however, been rare case reports of immunocompetent patients with esophagitis as well. It usually presents with odynophagia, fever, chest pain, and, rarely, gastrointestinal (GI) bleeding. It may or may not be accompanied by oral lesions as well. It is most commonly due to Candida, but can also be a result of CMV and HSV infection.

Diagnosis of infectious esophagitis usually needs to be done via endoscopy and biopsy. At times, barium swallow can show evidence of suspected esophagitis if ulcerations are significant enough to cause radiologically visible irregularities and ulcerations in the esophagus. However, patients with AIDS can be treated empirically with antifungal therapy based on symptoms and monitored for improvement. If they don’t show improvement within several days, then you should proceed to esophagogastroduodenoscopy (EGD) and biopsy to evaluate for other possible concomitant infections.

Nutritional status

In patients—both inpatients and outpatients—with any type of difficulty with PO intake, it is important to assess their nutritional status in order to develop a treatment plan. If patients have severe nutritional deficiency, more immediate treatment options may need to be considered. This can include alternative methods of enteral feeding that bypass the upper GI pathology such as total enteral nutrition (TEN) via a percutaneous endoscopic gastrostomy (PEG), gastrostomy tube (G-tube) or jejunostomy feeding tube (J-tube). In cases where the GI tract cannot be used, parenteral feeding should be considered. In addition to these options, if available at your institution, the nutrition team should be consulted for assistance in assessing and optimizing the patient’s nutritional status. Additionally, care should be taken to monitor the patient for refeeding syndrome once nutritional repletion is initiated.

IV. What's the evidence?

“Technical review on management of oropharyngeal dysphagia”. . vol. 116. 1999. pp. 455-478. (Provides extensive evaluation of oropharyngeal dysphagia, including a very detailed differential diagnosis which was duplicated in this chapter.)

Ravi, A, Christie J, Dysphagia, McKean, S, Ross, J, Dressler, D, Brotman, D, Ginsberg, J. “Aspiration and Swallowing Dysfunction”. McGraw-Hill. 2012. pp. 1245-1253.

Laine, L, Bonacini, M. “Esophageal disease in human immunodeficiency virus Infection”. Arch Intern Med. vol. 154. 1994. pp. 1577-1582.

Spieker, MR. “Evaluating dysphagia”. Am Fam Physician. vol. 61. 2000 Jun 15. pp. 3639-3648.

Palmer, JB, Drenna, JC, Baba, M. “Evaluation and treatment of swallowing impairments”. Am Fam Physician. vol. 61. 2000 Apr 15. pp. 2453-2462.

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Hospital Medicine

Dysphagia and odynophagia