Dysphagia

Dysphagia is difficulty in swa llowing. The term odynophagia
is used when swallowing causes pain. The
latter is more marked in ulcerative and inflammatory
lesions of food passages-oral cavi ty, oropharyn x and
oesophagus.
Aetiology
The ca use of dysphagia may be pre-oesophageal (i.e. due to
disturbance in the oral or pharyngeal phase of deglutition),
or oesophar;eal (when disturbance is in oesophageal
phase). This class ification is clinica lly useful as most of
the pre-oesophageal causes can be easily excluded by
phys ical examination while oesophageal ones require
in vestigation.
Pre-oesophageal Causes
(a) Oral phase. Normally, food must be masticated,
lubricated with saliva, converted into a bolus by movements
of tongue and then pushed into the pharynx by
elevation of the tongue against the hard palate. Any disturbance
in these events will cause dysphagia. Thus
cause may be:
(i) Disturbance in mastication: trismus, fractures of
mandible, tumours of the upper o r lower Jaw, disorders
of temporomandibular joints.
(ii) Disturbance in lubrication: xerostomia following radiotherapy,
M iku licz disease.
(iii) Disturbance in mobility, of tongue: paralysis of tongue,
painful ulcers, tumours of tongue, lingual abscess,
total glossectomy.
(i v) Defects of palate: cleft palate, oronasal fistula.
(v) Lesions of buccal cavity and floor of mouth: stomatitis,
ulcera tive les ions, Ludwig's angina.
(b) Pharyngeal phase. For a normal swallow, food
should enter the pharynx and then be directed towards
oesophageal opening. All unwanted communications
into the nasopharynx, larynx, oral cavity sh ould be
closed. Disturbances in this phase can arise from:
(i) Obstructive lesions of pharynx, e.g. tumours of
tonsil, soft palate, pharynx, base of tongue , supraglottic
larynx, or even obstruc tive hypertrophic
tonsils.
(i i) Inflammatory coruiitions , e.g. acute tonSillitis, peritonsillar
abscess, retro or para-pharyngea l abscess, acute
epiglottitis, oedema larynx.
(iii) Spasmodic conditions, e.g. tetanus, rabies.
(iv) Paralytic conditions. Paralysis of soft palate due to
diphtheria, bulbar palsy, cerebrovascular accidents.
They cause regurgitation into the nose.
Paralys is of larynx-lesions of vagus and bilateral
superior laryngea I nerves cause asp ira tion of food into
the larynx.
Oesophageal Causes
The lesions may lie in the lumen, on the wall or outside
the wall of oesophagus.
(a) Lumen. Obstruction to lumen can occur in atresia,
foreign body, strictures, benign or malignant tumours.
(b) Wall. It can be acute or chronic oesophagitis, or
motility disorde rs. The latter a re:
( i) Hypomotility disorders, e.g. achalasia, scleroderma,
amyo trophic lateral sclerosis.
(i i) Hypermotility disorders, e.g. cricopharyngeal
spasm, diffuse oesophageal spasm.
(c) Outside the wall. The lesions ~ause obstruction by
pressing on the oesophagus from outside:
(i) Hypopharyngeal diverticulum (see page 255).
(ii) H ia tus hernia.
(iii) Cervical osteophytes.
(iv) Thyroid les ions, e.g. en largement, tumours,
Hash imoto's thyroidi t is.
(v) Mediastinal lesions, e.g. tumours of mediastinum,
lymph node enlargement, ao rtic aneurysm, cardiac
enlargement.
(vi) Vascular rings (dysphagia lusoria).
Investigations
1. History. A detailed history is of paramount importa
nce. Ascertain, if dysphagia is of:
(i) Sudden onset (foreign body or impaction of food on
a preexisting stricture or malignancy, neurological
disorders),
(ii) Progressive (malignancy),
(iii) Intermittent (spasms or spasmodic episodes over an
organic les ion),
(iv) More to liquids (paralytic lesions),
(v) More to solids and progressing even to liquids
(malignancy or stricture),
(vi) Intolerance to acid food or fruit juices (ulcerative
lesions).
N ote any associated symptoms, e.g. regurgitation and
hea rt burn (hi atus hernia); regurgi tat ion of undigested
food while lying down, with cough at night (hypopharyngeal
diverticulum); asp iration into lungs (la ryngeal
paralysis); aspi ra tion into the nose (palatal pa ral ys is).
2. Clinical examination. Examination of oral cavity,
oropharynx, and larynx and hypopharynx can exclude
most of the pre-oesophageal causes of dysphagia.
Examination of the neck, chest and nervous system,
including cranial nerves should also be undertaken.
3. Blood examination. Haemogram is important in the
diagnosis and treatment of Plummer-Vinson syndrome
and to know the nutritional status of the patient.
4. Radiography
(a) X-ra)' chest: To exclude cardiovascular, pulmonary
and mediastinal diseases.
(b) Lateral view neck: To exclude cervical osteophytes
and any soft tissue les ions of post-cricoid or
retropharyngeal space.
(c) Barium swallow: It is useful in the diagnosis of malignancy,
cardiac achalas ia, strictures, diverticula; hiatus
hernia or oesophageal spasms. Combined with
fluoroscop ic control or cineradiography, it can help
in the diagnosis of motility disorders of oesophageal
wall or sphincters.
5. Manometric and pH studies. A pressure transducer
along with a pH electrode and an open-tipped catheter is
introduced into the oesophagus to measure the pressures
in the oesophagus and at its sphincters. Acid reflux into
the oesophagus is measured by pH electrode. It also
measures the effectiveness of oesophagus to clear the .ac id
load after acid solution is put in the oesophagus. These
studies help in motility disorders, gastro-oesophageal
reflux and to find whether oesophageal spasms are spontaneous
or acid-induced.
6. Oesophagoscopy. It gives direct examination of
oesophageal mucosa and permits biopsy specimens.
Flexible fibre-optic or rigid scopes can be used.
7. Other investigations. Bronchoscopy (for bronchial
carc inoma), cardiac catheterisation (for vascular anomalies),
thyroid scan (for malignant thyroid) may be required,
depending on the case.