Dysphagia: Pathophysiology/Causes, Diagnosis, Treatment

Dysphagia is also called as difficulty in swallowing. It can be due to any obstruction to food while going from mouth to esophagus. There is a term called as aphagia which is inability to swallow. Odynophagia refers to as painful swallowing. The problem of dysphagia is a major issue and can disturb the normal lifestyle of the individuals. It can cause nutritional problems, aspiration issues and various important macro and micronutrient deficiencies.

Dysphagia Pathophysiology/Causes

Dysphagia is categorized into various types based on the location and after that there are different causes which leads to dysphagia. These are:

1. Oropharyngeal Dysphagia- Oral dysphagia implies the inability of the food to go through the oral cavity into the pharynx, this is due to difficulty in initiating the process of swallowing. There is drooling and there is a possibility of regurgitation of food into the nose or aspiration into the trachea. Pharyngeal dysphagia is due to inability to food to pass from pharynx and it can be due to poor pharyngeal propulsion or due to obstruction at the level of Upper Esophageal Sphincter.

•  The causes are:
  • The structural causes are:
    • Zenker’s Diverticulum
    • Neoplasm
    • Cervical web
    • Congenital abnormalities
    • Radiation
    • Infection
    • Corrosive Injury

• The Propulsion causes can be Neurogenic and Myogenic, Firstly the Neurogenic Causes are:
  • Parkinsonism
  • Cerebrovascular Accident
  • Amyotropic Lateral Sclerosis
  • Brainstem tumour
  • Gullian-Barre syndrome
  • Multiple Sclerosis
  • Cerebral Palsy.
• The Myogenic Causes are:
  • Myasthenia Gravis
  • Polymyositis
  • Mixed Connective tissue disorders
  • Sarcoidosis

2. Esophageal dysphagia: Esophageal dysphagia refers to the difficulty of food to go through the esophagus passage. It can lead to regurgitation of food or sensation of food being stuck in the esophagus. The reasons are poorly masticated food, any obstruction to the pathway of food by any tumour or stricture or There might be the poor propulsive action of the pharyngeal muscles. The causes can be structural or propulsive. The causes are:
3. Propulsive Dyspagia - In this case there will be a dysphagia to both solid and liquid food. The causes are:
   • GERD with weak perstalsis
   • Achalasia 
   • Diffuse esophageal spasm 
   • Scleroderma
4. Structural Dysphagia- It causes dysphagia to mainly solid foods. The causes are:
   • Schatzki ring
   • Esophageal web
   • Neoplasm
   • Eosinophilic esophagitis 
   • Radiation esophagitis
   • Congenital esophageal stenosis
5. Some of the structural causes can lead to pain on swallowing ( Odynophagia). The causes of Odynophagia are:
   • Pill Esophagitis
   • Infectious esophagitis
   • Caustic injury
   • Chemotherapy
   • Sclerotherapy
   • Crohn’s disease
   • Lichen planus

Dysphagia Diagnosis

• The most important aspect for diagnosing the dysphagia is History taking. It is very important to notice the localization of dysphagia ( For example- dysphagia localizing to the chest is esophageal) , the associated symptoms ( for example- Nasal regurgitation and tracheobronchial aspiration alongwith coughing are signs of oropharyngeal dysphagia), the circumstances ( Corrosive ingestion) and the progression.
• The type of food causing the dysphagia is also very important to consider because the solid dysphagia is mainly due to structural issues whereas dysphagia to both liquid and solid tells us about possibility of esophageal motor difficulties.
• Immunocompromized patients like AIDS patients can suffer esophagitis from opportunistic infections like Candida, Herpes Simplex virus or Cytomegalovirus.
• Medication history should be noticed thoroughly as some medications like tetracyclines can acuse Pill induced esophagitis. Opiods can cause esophageal dysmotility.
• If any oral or pharyngeal dysphagia is suspected ,a videofluorocopic swallow study is the first step of diagnosis. But if the dysphagia at the level of Esophagus is suspected then endoscopy is the first choice.
• If the motility disorder is suspected then Barium swallow followed by possible manometry is the diagnostic method of choice.

Also Read: Important Ent Surgeries : Adenoidectomy, Tonsillectomy, Septoplasty

Dysphagia Treatment

Different conditions causing dysphagia has different management.

• Achalasia causing dysphagia can be treated with Botulinum toxin or CCBs. The efforts for dilation should not be done as there is a risk of perforation.
• Scleroderma is treated with PPI. Because the esophagus gets swollen due to more and more reflux.
• Diffuse esophageal spasm dysphagia can be managed using Calcium channel blockers and sometimes nitrates.
• Schatzki rings are managed using mechanical dilation or balloon dilators.
• Plummer vinson syndrome has a risk of esophageal cancer therefore esophagogastroduodenoscopy should be done and biopsy should be taken to confirm if its cancer or not.
• Zenker’s diverticulum is treated with open/endoscopic surgery or cricopharyngeal myotomy.
• Esophageal Cancer requires chemoradiation and Surgery.

Also Read: Gene Therapy: A Journey into the Future of Medicine

Hope you found this blog helpful for your ENT residency head and neck preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.

Propel your ENT Residency Preparation! Access conceptual video lectures, QBank, Mock Tests, and premium study resources on the PrepLadder App. Download it today!