Dysphagia

Question 1

What are the two main pathological mechanisms in persistent dysphagia?

Answer 1

Mechanical/obstructive and neuromuscular (CNS or localised, neurogenic or auto-inflammatory)

Question 2

What are acute causes of dysphagia?

Answer 2

• Trauma/foreign body
• Acute throat infection
• Acute oesophagitis - infectious or allergic e.g. eosinophillic
• Stroke

Question 3

What are the different onset of dysphagia? What is an important characteristic to determine?

Answer 3

Acute, chronic/gradual, intermittent.

Important to ask whether it is food and fluid from the start - if no and progresssive, suspect malignancy or growing obstructive problem.

Question 4

Describe the anatomy and physiology of swallowing.

Answer 4

Swallowing involves the coordinated action of the mouth, pharynx, and esophagus.

It has three phases: oral (voluntary), pharyngeal (involuntary), and esophageal (involuntary). The process is controlled by the swallowing center in the brainstem.

Question 5

What are common symptoms associated with dysphagia?

Answer 5

• Regurgitation of food or drink,
• coughing or choking during eating,
• bubbling or gurgling or bad breath
• pain on swallowing (odynophagia), and
• weight loss/anorexia

Question 6

What are benign and acute causes of dysphagia? What is the predominant symptoms?

Answer 6

Infection e.g. tonsillitis

Often with pain/ sore throat

Question 7

What are three secondary problems associated with dysphagia that may be life-threatening?

Answer 7

• Aspiration
• Malnutrition/dehydration
• Difficulty taking medication

Question 8

How can you classify obstructive pathologies of dysphagia?

Answer 8

• Intrinsic: oesophageal tumour or stricture, pouch
• Extrinsic: mediastinal mass

Question 9

List important associated features of dysphagia to ask about.

Answer 9

• Difficulty initiating or coordinating - CNS
• Coughing/choking - aspiration
• Pain - wall damage
• Regurgitation - obstructive
• Voice changes
• Neck lump

Question 10

What are some oropharyngeal causes of dysphagia? How might you differentiate it from an oesophageal cause?

Answer 10

• neurological problems (e.g., stroke, Parkinson’s disease) - poor coordiation, inability to chew
• Dementia - loss of voluntary action of swallowing
• Myasthenia gravis
• infections (e.g., poor dentition, severe tonsillitis, candidiasis, epiglottitis)
• Oropharyngeal tumors,
• pharyngeal pouch,

Differentiated by difficulty initiating a swallow, symptoms of aspiration e.g. choking and coughing

Question 11

What are some oesophageal causes of dysphagia?

How might you differentiate it from an oropharyngeal cause - list 3 symptoms?

Answer 11

• oesophagitis/eosinophilic,
• oesophageal cancer or mediastinal tumour
• Benign strictures,
• oesophageal webs and rings,
• achalasia - degenerative condition
• Systemic sclerosis - oesophageal dysmotility

Difficulty passing food - sensation of food sticking in chest or throat, regurgitation

Question 12

A person with a neurologcial condition presents with dysphagia. What could it be? List 5 conditions (CNS and PNS)

Answer 12

• Stroke/ cellebellar disease
• Facial nerve palsy
• Parkinson’s disease,
• multiple sclerosis,
• Motor neurone disease
• Myasthenia gravis

Coordination, aspiration

Question 13

What is a pharyngeal pouch also called?

Answer 13

Zenker’s diverticulum.

Question 14

What is odynophagia caused by? Is it a red flag?

Answer 14

Damage to the oesophagus or forceful contractions.
* Oesophagitis (infection, auto-immune due to medication, acid reflux)
* Ulceration (acid reflux, malignancy)
* Oesophageal spasms

Red flag for malignancy. Oesophageal cancer may first present with odynophagia.

Question 15

A patient with GORD presents with dysphagia. Why is this?

Answer 15

Lower oesophageal stricture

Question 16

A woman with heavy menstrual bleeding complains of tiredness and food being stuck in the chest. What is the likely cause of her dysphagia?

Answer 16

Oesophageal web - can happen in iron-deficiency anaemia

Question 17

Which medical history is relevant in a patient with dysphagia?

Answer 17

• Damage or radiation to the mouth, throat, or oesophagus
• GORD- chronic acid reflux
• Neurological conditions

Other: medication, cancer RFs

Question 18

What about odynophagia should you ask about?

Answer 18

• Site/location (mouth, throat, chest)
• Progression - intermittent or progressive/constant

Chest - may suggest oesophageal problem

Question 19

How might you determine the location of pathology in dysphagia?

Answer 19

Open question of the characteristic of dysphagia - e.g. how does it feel like?

Initation of swallow and food moving down

Question 20

Why is it important to ask about progression of dysphagia? e.g. food or fluid first affected

Answer 20

Suspect malignancy if progressive.

Benign causes include new strictures.

Question 21

What pathological mechanism does regurgitation suggest?

e.g. A patient reports progressive difficulty swallowing solid foods over the past six months, with occasional regurgitation of undigested food.

Answer 21

Obstruction e.g. stricture, tumour, achalasia (inc. LOS tone)

Question 22

What are the key components of a physical examination for a patient with dysphagia?

Answer 22

Assessing the oral cavity, neck, neurological function and respiratory exam.

If possible, observe the patient swallowing different consistencies of food and liquids

Question 23

Describe the diagnostic tests used to evaluate dysphagia (e.g., barium swallow, endoscopy, manometry)

Answer 23

Barium Swallow: X-ray imaging to visualize the swallowing process and detect structural abnormalities.

Endoscopy: Direct visualization of the esophagus and stomach to identify inflammation, strictures, or tumors.

Manometry: Measures the pressure and coordination of esophageal muscles during swallowing.

Videofluoroscopy: Dynamic X-ray study to assess the oral and pharyngeal phases of swallowing.

Question 24

General management for dysphagia

Answer 24

1. Dietary modications or nutritional supplementation
2. Swallowing therapy
3. Treatement of underlying cause - medical or surgical

Question 25

A 70-year-old patient presents with progressive difficulty swallowing solids and liquids, weight loss, and regurgitation. What is your differential diagnosis?

Answer 25

Differential diagnosis includes esophageal cancer, achalasia, esophageal stricture/ severe GERD.

Question 26

What is a quick imaging test for dysphagia? Especially if suspecting chest involvement or foreign body?

Answer 26

CXR