dysphagia is difficulty with the act of swallowing solids or liquids. It may be subjective or objective and can refer to the sensation of not being able to swallow, food 'sticking' or not passing, choking episodes, or aspiration of food and/or liquids. It should be distinguished from odynophagia (pain on swallowing) and globus sensation (sensation of a lump in the throat between meals). Dysphagia can be caused by functional or structural abnormalities of the oral cavity, pharynx, oesophagus, or gastric cardia
Investigations: BMJ (2023)
Patients presenting with associated neurological symptoms or physical findings without other aetiologies for dysphagia may require further evaluation. Laboratory assessment is usually ordered in oropharyngeal dysphagia to assess the neuromuscular causes
Pharyngeal dysphagia can manifest with drooling or spillage of food, post-nasal regurgitation, hoarseness, shortness of breath, coughing, choking, and dysphonia.
Patients with oesophageal dysphagia often report food sticking in their lower neck or mid-chest region. Patients may use different manoeuvres to help the food passing the oesophagus, or they may sip water to relieve the obstruction.
Patients with oral dysphagia most often have problems initiating the swallow or in controlling the food in their mouth.
The key tests used for the evaluation of dysphagia are oesophagogastroduodenoscopy (OGD), barium x-ray, fibre-optic nasopharyngeal laryngoscopy, or oesophageal manometry. However, the choice of specific testing depends on the clinical presentation.
investigations: Patients presenting with associated neurological symptoms or physical findings without other aetiologies for dysphagia may require further evaluation. Laboratory assessment is usually ordered in oropharyngeal dysphagia to assess the neuromuscular causes
BMJ (2023)
hyroid function test (thyromegaly)
Cerebrospinal fluid analysis (multiple sclerosis)
Botulinum toxin assay
Liver enzymes
Ceruloplasmin levels (Wilson's disease)
24-hour urinary copper (Wilson's disease)
Creatine phosphokinase (inflammatory myopathies)
Acetylcholine receptor antibodies (myasthenia gravis)
Anti-DNA and antinuclear antibodies (scleroderma).
Fibre-optic nasopharyngoscopy/laryngoscopy
swallow test
urgent referrals BMJ (2023)
Caustic injury:Caustic injury can cause acute dysphagia, odynophagia, tongue oedema, stridor, airway obstruction, aspiration, or perforation. It can also lead to cyanosis, hypoxia, fever, tachycardia, and shock.
Stroke:Some 40% to 70% of people with stroke experience dysphagia.[2] The consequence of dysphagia in this population can be aspiration of solid and/or liquid food into the respiratory tract, which can lead to life-threatening pneumonia
foreign body:Acute dysphagia can be due to foreign bodies and food impaction in the pharynx or oesophagus. Associated symptoms include odynophagia, foreign body sensation, and excessive secretions
Causes of dysphagia NHS (2021):
REFERENCES
Other signs of dysphagia include: NHS (2021)
coughing or choking when eating or drinking
bringing food back up, sometimes through the nose
a sensation that food is stuck in your throat or chest
persistent drooling of saliva
being unable to chew food properly
a gurgly, wet-sounding voice when eating or drinking
Over time, dysphagia can also cause symptoms such as weight loss and repeated chest infections.
Dysphagia is usually caused by another health condition, such as:
a condition that affects the nervous system, such as a stroke, head injury, multiple sclerosis or dementia
cancer – such as mouth cancer or oesophageal cancer
gastro-oesophageal reflux disease (GORD) – where stomach acid leaks back up into the oesophagus
Children can also have dysphagia as a result of a developmental or learning disability, such as cerebral palsy.
Read more about the causes of dysphagia.
Treating dysphagia NHS(2021)
Treatment usually depends on the cause and type of dysphagia.
Many cases of dysphagia can be improved with careful management, but a cure isn't always possible.
Treatments for dysphagia include:
speech and language therapy to help people recover their swallowing with special exercises and techniques
changing the consistency of food and liquids to make them safer to swallow
other forms of feeding – such as tube feeding through the nose or stomach
surgery to widen the oesophagus, by stretching it or inserting a plastic or metal tube (stent)
Complications of dysphagia NHS (2021)
One of the most common problems is coughing or choking, when food goes down the "wrong way" and blocks your airway. This can lead to chest infections, such as aspiration pneumonia, which require urgent medical treatment.
Aspiration pneumonia can develop after accidentally inhaling something, such as a small piece of food.
Warning signs of aspiration pneumonia include:
a wet, gurgly voice while eating or drinking
coughing while eating or drinking
difficulty breathing – breathing may be rapid and shallow
CKS (2022) dysphagia in pregnancy,
Red flag or alarm symptoms which should prompt consideration of a more serious condition or the need for urgent investigation include:
Difficulty swallowing (dysphagia).
Hoarse voice.
Recurring or persistent cough.
Upper or lower gastrointestinal tract bleeding.
Weight loss.
Lymphadenopathy.
Epigastric or supraclavicular mass.
referring on when suspicion of any GI cancer CKS (2022)
Referral timelines
The terms used in the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral are as follows:
Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
Urgent: to happen/be performed within 2 weeks.
Very urgent: to happen within 48 hours.
Non-urgent: the timescale generally used for a referral or investigation that is not considered very urgent or urgent.
Suspected cancer pathway referral: the patient is seen within the national target for cancer referrals.
When should I refer a person with suspected oesophageal cancer?
Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
With dysphagia, or
Aged 55 years and over with weight loss and any of the following:
Upper abdominal pain.
Reflux.
Dyspepsia.
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