Dysphagia

Question 1

What are the two main classes of dysphagia?

Answer 1

1. Neuromuscular - Affects the 1st and 2nd phase of swallowing
   a. Muscular (muscular dystrophy, myasthenia gravis)
   b. Neurological (stroke, Parkinson’s disease, Multiple Sclerosis)
   c. Weakened muscles, impaired coordination (in elderly)
2. Narrowing of the throat/oesophagus – affects the 3rd phase of swallowing
   a. Throat cancer, oesophageal cancer
   b. Sac/rings in oesophagus
   c. Gastric reflux (GERD)

Question 2

What complications are associated with dysphagia?

Answer 2

1. Choking
2. Pulmonary aspiration
3. Malnutrition

Question 3

What treatment is available for dysphagia?

Answer 3

1. Speech and language therapy -Muscle exercises
2. Change in head/neck position
3. SALT assessment: Soft food/thickened drinks
4. Surgery (remove narrowed areas of oesophagus)
5. Tube feeding to ensure nutrition level is sufficient
6. Endoscopic dilatation
7. Botox (used for achalasia) to relax the stiffened muscle
8. Stent insertion for mechanical blockages to open the oesophagus fully.

Question 4

What causes dysphagia?

Answer 4

Mechanical block
- Malignant stricture: Oesophageal cancer, Gastric cancer, Pharyngeal cancer
- Benign stricture: Oesophageal web or ring, peptic stricture
- Extrinsic pressure: lung cancer, mediastinal lymph nodes, retrosternal goitre, aortic aneurysm, left atrial enlargement
Pharyngeal pouch

Motility disorders:

• Achalasia
• Diffuse oesophageal spasm
• Systemic sclerosis
• Neurological bulbar palsy
• Wilson’s or Parkinson’s disease
• Myasthenia gravis

Other:

• Oesophagitis
• Globus

Question 5

Key questions to ask about dysphagia?

Answer 5

1. Was there difficulty swallowing solids AND liquids from the start?
   Yes: motility disorder
   No: solids then liquids, suspect a stricture
2. Is it difficult to make the swallowing movement?
   Yes: suspect bulbar palsy, especially if patient coughs on swallowing
3. Is swallowing painful (odynophagia)?
   Yes: suspect cancer, oesophageal ulcer (benign or malignant), candida or spam
4. Is the dysphagia intermittent or is it constant and getting worse?
   Intermittent; Suspect oesophageal spasms
   Constant and worsening: suspect malignant stricture
5. Does the neck bulge or gurgle on drinking?
   Yes: suspect a pharyngeal pouch

Question 6

Which examinations signs should be investigated in a history of dysphagia?

Answer 6

Cachetic or anaemia?
Mouth examination
Supraclavicular nodes
Goitre examinaiton 
Neurological disease

Question 7

How does diffuse oesophageal spasm present?

Answer 7

Intermittent dysphagia and chest pain

Question 8

How does achalasia present?

Answer 8

The lower oesophageal sphincter fails to relax (due to degeneration of the myenteric plexus), causing dysphagia (fluid +solid), regurgitation, substernal cramps and weight loss