Professional Documents
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Nasal speech.
TABLE 1. Causes of Oropharyngeal Dysphagia Drooling.
Mechanical and obstructive causes Diminished cough reflex.
Infections (eg, retropharyngeal abscesses) Choking (note that laryngeal penetration and aspiration
Thyromegaly may occur without concurrent choking or coughing).
Lymphadenopathy Dysarthria and diplopia (may accompany neurological
Zenker diverticulum
conditions that cause oropharyngeal dysphagia).
Reduced muscle compliance (myositis, fibrosis,
cricopharyngeal bar)
Halitosis in patients with a large, residue-containing
Eosinophilic esophagitis Zenker diverticulum or in patients with advanced
Head and neck malignancies and the consequences achalasia or long-term obstruction, with luminal accu-
(eg, hard fibrotic strictures) of surgical and/or radiotherapeutic mulation of decomposing residue.
interventions on these tumors Recurrent pneumonia.
Cervical osteophytes Precise diagnosis is possible when there is a definite
Oropharyngeal malignancy and neoplasms (rare) neurological condition accompanying the oropharyngeal
Neuromuscular disturbances dysphagia, such as:
Central nervous system diseases such as stroke, Parkinson Hemiparesis following an earlier cerebrovascular
disease, cranial nerve, or bulbar palsy (eg, multiple sclerosis,
motor neuron disease), amyotrophic lateral sclerosis accident.
Contractile disturbances such as myasthenia gravis, Ptosis of the eyelids and fatigability, suggesting myas-
oculopharyngeal muscular dystrophy, and others thenia gravis.
Stiffness, tremors, and dysautonomia, suggesting Par-
kinson disease.
Other neurological diseases, including cervical dystonia and
of the perceived swallowing problem: oropharyngeal versus compression of the cranial nerves, such as hyperostosis or
esophageal dysphagia. Arnold-Chiari deformity (hindbrain herniations).
Specific deficits of the cranial nerves involved in
Oropharyngeal Dysphagia swallowing may also help pinpoint the origin of the
Clinical History oropharyngeal disturbance, establishing a diagnosis.
Oropharyngeal dysphagia can also be called “high”
dysphagia, referring to oral or pharyngeal locations. Patients Testing
have difficulty in initiating a swallow, and they usually Tests for evaluating dysphagia can be chosen
identify the cervical area as the area presenting a problem. depending on the patient’s characteristics, the severity of
In neurological patients, oropharyngeal dysphagia is a the problem, and the available expertise. Stroke patients
highly prevalent comorbid condition associated with should be screened for dysphagia within the first 24 hours
adverse health outcomes including dehydration, malnu- after the stroke and before oral intake, as this leads to a 3-
trition, pneumonia, and death. Impaired swallowing can fold reduction in the risk of complications resulting from
cause increased anxiety and fear, which may lead to dysphagia. Patients with persistent weight loss and recur-
patients avoiding oral intake—resulting in malnutrition, rent chest infections should be urgently reviewed.5
depression, and isolation. A bedside swallow evaluation protocol has been devel-
Frequent accompanying symptoms: oped by the American Speech-Language-Hearing Associa-
Difficulty initiating a swallow, repetitive swallowing. tion (ASHA); a template is available at: http://www.speaking
Nasal regurgitation. ofspeech.info/medical/BedsideSwallowingEval.pdf. This in-
Coughing. expensive bedside tool provides a detailed and structured
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. www.jcge.com | 371
Malagelada et al J Clin Gastroenterol Volume 49, Number 5, May/June 2015
approach to the mechanisms of oropharyngeal dysphagia recording the time taken and number of swallows.
and its management, and it may be useful in areas with The speed of swallowing and the average volume per
constrained resources. swallow can be calculated from these data. It is
Major tests for evaluating oropharyngeal dysphagia reported to have a predictive sensitivity of >95% for
are: identifying the presence of dysphagia, and it may be
Video fluoroscopy, also known as the “modified barium complemented by a “food test” using a small amount
swallow” of pudding placed on the dorsum of the tongue.12
The algorithm shown in Figure 1 provides an indica-
This is the gold standard for evaluating orophar- tion of more sophisticated tests and procedures that are
yngeal dysphagia.6–8 needed to pursue a diagnostic investigation leading to
Swallowing is recorded on video during fluoroscopy, specific therapies.
providing details of the patient’s swallowing mechanics.
It may also help predict the risk of aspiration
pneumonia.9
Esophageal Dysphagia
Video-fluoroscopic techniques can be viewed at Differential Diagnosis
slower speeds or frame by frame and can also be The most common conditions associated with esoph-
transmitted via the Internet, facilitating interpreta- ageal dysphagia are:
tive readings at remote sites.10 Peptic stricture—occurs in up to 10% of patients with
gastroesophageal reflux disease,13,14 but the incidence
Upper endoscopy decreases with proton-pump inhibitor use.
Nasoendoscopy is the gold standard for evaluating Esophageal neoplasia—including cardia neoplasia and
structural causes of dysphagia6–8—for example, pseudoachalasia.
lesions in the oropharynx—and inspection of pooled Esophageal webs and rings.
secretions or food material. Achalasia, including other primary and secondary
This is not a sensitive means of detecting abnormal esophageal motility disorders.
swallowing function. Scleroderma.
It fails to identify aspiration in 20% to 40% of cases Spastic motility disorders.
when followed up with video fluoroscopy, due to the Functional dysphagia.
absence of a cough reflex. Radiation injury.
Rare causes:
Fiberoptic endoscopic evaluation of swallowing (FEES) Lymphocytic esophagitis.
FEES is a modified endoscopic approach that involves Cardiovascular abnormalities.
visualizing the laryngeal and pharyngeal structures Esophageal Crohn’s involvement.
through a transnasal flexible fiberoptic endoscope Caustic injury.
while food and liquid boluses are given to the patient.
Clinical History
Pharyngoesophageal high-resolution manometry (HRM) Esophageal dysphagia can also be called “low” dys-
This is a quantitative evaluation of the pressure and phagia, referring to a probable location in the distal
timing of pharyngeal contraction and upper esoph- esophagus—although it should be noted that some patients
ageal relaxation. with forms of esophageal dysphagia such as achalasia may
It can be used in conjunction with video fluoroscopy perceive it as being located in the cervical region, mimicking
to allow a better appreciation of the movement and oropharyngeal dysphagia.
pressures involved. Dysphagia that occurs equally with solids and liquids
It may have some value in patients with orophar- often involves an esophageal motility problem. This
yngeal dysphagia despite a negative conventional suspicion is reinforced when intermittent dysphagia for
barium study. solids and liquids is associated with chest pain.
It may be useful when surgical myotomy is being Dysphagia that occurs only with solids but never with
considered. liquids suggests the possibility of mechanical obstruc-
tion, with luminal stenosis to a diameter of <15 mm. If
Automated impedance manometry11 the dysphagia is progressive, peptic stricture or carci-
This is a combination of impedance and HRM. noma should be considered in particular. It is also worth
Pressure-flow variables derived from automated noting that patients with peptic strictures usually have a
analysis of combined manometric/impedance meas- long history of heartburn and regurgitation, but no
urements provide valuable diagnostic information. weight loss. Conversely, patients with esophageal cancer
When they are combined to provide a score on the tend to be older men with marked weight loss.
swallow risk index, these measurements are a robust In case of intermittent dysphagia with food impaction,
predictor of aspiration. especially in young men, eosinophilic esophagitis should
be suspected.
Water swallow test The physical examination of patients with esophageal
dysphagia is usually of limited value, although cervical/
This is inexpensive and is a potentially useful basic supraclavicular lymphadenopathy may be palpable in
screening test alongside the evidence obtained from patients with esophageal cancer. Some patients with scle-
the clinical history and physical examination. roderma and secondary peptic strictures may also present
It involves the patient drinking 150 mL of water from with CREST syndrome (calcinosis, Raynaud phenomenon,
a glass as quickly as possible, with the examiner esophageal involvement, sclerodactyly, and telangiectasia).
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J Clin Gastroenterol Volume 49, Number 5, May/June 2015 Dysphagia Global Guidelines and Cascades
No evidence of
systemic process
Nasoendoscopy to
Videofluoroscopic swallowing ± manometry to characterize severity and
evaluate structural
causes of dysphagia mechanism of swallow dysfunction
Dysfunction potentially
Identify structural Severe dysfunction or Dysfunction
amenable to therapy:
lesions with specific risk of aspiration potentially emenable
swallow therapy,
Rx: e.g. tumors, pneumonia: non-oral to cricopharyngeal
± temporary non-oral
Zenker’s feeding, tracheostomy? myotomy
feeding
FIGURE 1. Evaluation and management of oropharyngeal dysphagia. CNS indicates central nervous system.
Halitosis is a very nonspecific sign that may suggest If available, high-resolution video endoscopy can be
advanced achalasia or long-term obstruction, with accu- used to detect subtle changes, such as the typical
mulation of slowly decomposing residues in the esophageal whitish islands in eosinophilic esophagitis.
lumen. Introducing the endoscope into the gastric cavity is
The clinical history is the cornerstone of evaluation very important to exclude pseudoachalasia due to a
and should be considered first. A major concern with tumor of the esophagogastric junction.
esophageal dysphagia is to exclude malignancy. The Endoscopy makes it possible to obtain tissue samples
patient’s history may provide clues. Malignancy is likely if and carry out therapeutic interventions.
there is: Endoscopic ultrasound is useful in some cases of
A short duration— < 4 months. outlet obstruction.
Disease progression.
Dysphagia more for solids than for liquids. Barium-contrast esophagram (barium swallow):
Weight loss.
In contrast, achalasia is more likely if: Barium esophagrams taken with the patient supine and
There is dysphagia for both solids and liquids. Dyspha- upright can outline irregularities in the esophageal lumen
gia for liquids strongly suggests the diagnosis. and identify most cases of obstruction, webs, and rings.
There is passive nocturnal regurgitation of mucus or A barium examination of the oropharynx and esoph-
food. agus during swallowing is the most useful initial test in
There is a problem that has existed for several months or patients with a history or clinical features suggesting a
years. proximal esophageal lesion. In expert hands, this may
The patient takes additional measures to promote the be a more sensitive and safer test than upper endoscopy.
passage of food, such as drinking or changing body It can also be helpful for detecting achalasia and
position. diffuse esophageal spasm, although these conditions
Eosinophilic esophagitis is more likely if there is: are more definitively diagnosed using manometry.
Intermittent dysphagia associated with occasional food It is useful to include a barium tablet to identify
impaction. subtle strictures. A barium swallow may also be
helpful in dysphagic patients with negative endo-
scopic findings if the tablet is added.
Testing A full-column radiographic evaluation15 is helpful if
The medical history is the basis for initial testing. a subtle mechanical impediment is suspected despite
Patients usually require early referral, as most will need an a negative upper endoscopic evaluation.
endoscopy. The algorithm shown in Figure 2 outlines A timed barium esophagram is very useful for
management decision making on whether endoscopy or a evaluating achalasia before and after treatment.
barium swallow should be the initial test employed.
Esophageal manometry:
Endoscopic evaluation:
This diagnostic method is based on recording
A video endoscope (fiberoptic endoscopes have largely pressure in the esophageal lumen using either solid-
been replaced by electronic or video endoscopes) is state or perfusion techniques.
passed through the mouth into the stomach, with Manometry is indicated when an esophageal cause of
detailed visualization of the upper gastrointestinal tract. dysphagia is suspected after an inconclusive barium
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Malagelada et al J Clin Gastroenterol Volume 49, Number 5, May/June 2015
Esophageal dysphagia
Esophageal
Achalasia Scleroderma Endoscopy
spasm
Barium swallow
FIGURE 2. Evaluation and management of esophageal dysphagia. GERD indicates gastroesophageal reflux disease.
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J Clin Gastroenterol Volume 49, Number 5, May/June 2015 Dysphagia Global Guidelines and Cascades
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Malagelada et al J Clin Gastroenterol Volume 49, Number 5, May/June 2015
Exceptionally, an endoluminal prosthesis may be indi- For patients with a treatable motility disorder such as
cated in patients with benign strictures.25 The risk of achalasia, therapy is directed at the motility problem.
perforation is about 0.5% and there is a high rate of If a treatable motility disorder is not found, endoscopy is
stent migration in these conditions. repeated to confirm that esophagitis has healed and that
Surgery is generally indicated if frank perforation occurs, the ring has been disrupted.
but endoscopic methods of wound closure are being For patients with persistent rings, another trial of
developed. dilation is usually warranted.
Refractory rings that do not respond to dilation using
Treatment of Lower Esophageal Mucosal Rings standard balloons and bougies may respond to endo-
(Including Schatzki Ring) scopic electrosurgical incision and surgical resection.
Dilation therapy for lower esophageal mucosal rings These therapies should be required only rarely for
involves the passage of a single large bougie (45 to 60 Fr) patients with lower esophageal mucosal rings, and only
or balloon dilation (18 to 20 mm) aimed at fracturing after other causes of dysphagia have been excluded.
(rather than merely stretching) the rings.
After abrupt dilation, any associated reflux esophagitis is Achalasia
treated aggressively with high-dose proton-pump The possibility of pseudoachalasia (older age, fast and
inhibitors. severe weight loss) or Chagas disease should be excluded.
The need for subsequent dilations is determined empiri- The management of achalasia depends largely on the
cally. However, recurrence of dysphagia is possible, and surgical risk.
patients should be advised that repeated dilation may be Medical therapy with nitrates or calcium-channel block-
needed subsequently. Esophageal mucosal biopsies ers is often ineffective or poorly tolerated.
should be obtained in such cases to evaluate for possible Botulinum toxin injection may be used as an initial therapy
eosinophilic esophagitis. for patients who have a poor surgical risk, if the clinician
Esophageal manometry is recommended for patients considers that medications and pneumatic dilation would
whose dysphagia persists or returns quickly despite be poorly tolerated. Botulinum toxin injection appears to be
adequate dilation and antireflux therapy. a safe procedure that can induce a clinical remission for at
Repeat as
Refer to a specialized center Nifedipine
needed
Pneumatic Repeat
Esophagectomy
dilation myotomy
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J Clin Gastroenterol Volume 49, Number 5, May/June 2015 Dysphagia Global Guidelines and Cascades
TABLE 7. Cascade: Management Options for Oropharyngeal TABLE 9. Cascade: Management Options for Achalasia
Dysphagia
Limited resources
Limited resources Balloon dilation
Swallowing reeducation Surgery
Food consistency modification; citric acid and other additives Medium resources
Drugs for Parkinsonism or myasthenia, if appropriate Surgery (myotomy + antireflux)
Feeding tube State of the art
Medium resources Peroral endoscopic myotomy
Cricopharyngeal myotomy/Zenker, if feasible Esophagectomy with neoesophagus in extreme cases
Surgical gastrostomy
Angiotensin-converting enzyme inhibitors to facilitate cough
State-of-the-art The diagnosis is based on histologic examination of
Endoscopic gastrostomy mucosal biopsies from the upper and lower esophagus
after initial treatment with proton-pump inhibitors for 6
to 8 weeks. Approximately one third of patients with
least 6 months in approximately two thirds of patients with suspected eosinophilic esophagitis achieve remission with
achalasia. However, most patients will need repeated proton-pump inhibitor therapy.27
injections to maintain the remission. The long-term results Identification of the underlying food or airborne allergen
with this therapy have been disappointing, and some can direct dietary advice.
surgeons feel that surgery is made more difficult by the A 6-food elimination diet can be tried if specific allergens
scarring that may be caused by injection therapy. cannot be identified.
When these treatments have failed, the physician and Standard recommendations for pharmacologic therapy
patient must decide whether the potential benefits of of eosinophilic esophagitis include topical corticosteroids
pneumatic dilation or myotomy outweigh the substantial and leukotriene antagonists.28,29
risks that these procedures pose for elderly or infirm Esophageal dilation for patients with associated stric-
patients. tures and rings is safe (with a true perforation rate of
For those in whom surgery is an option, most gastro- <1%) and effective (with dysphagia improving for up to
enterologists will start with pneumatic dilation with 1 to 2 y in over 90% of cases).30,31
endoscopy and opt for laparoscopic Heller-type myot-
omy in patients in whom 2 or 3 graded pneumatic Management Cascades
dilations (with 30-, 35-, and 40-mm balloons) have failed. Tables 7 to 9 list alternative management options for
Some gastroenterologists prefer to opt directly for situations with limited resources, medium-level resources,
surgery without a prior trial of pneumatic dilation, or or “state-of-the-art” resources.
limit the diameter of pneumatic dilators used to 30 to
35 mm. References
Peroral endoscopic myotomy is becoming available as an
alternative to either pneumatic dilation or Heller myotomy. General References
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dilation or myotomy, but many neurologically intact dilation in adults with eosinophilic oesophagitis. Aliment
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