Dysphagia

Scope

  • Diagnosis and management of dysphagia in adults within:
    • Primary care includes initial assessment and indications for further investigation or referral to secondary care
Definition
  • Dysphagia can be divided into:
    • oropharyngeal dysphagia (also known as 'high' dysphagia) - difficulty in initiating a swallow
    • oesophageal dysphagia (also known as 'low' dysphagia) - the sensation that foods or liquids are being hindered in their passage from the mouth to the stomach the causes of dysphagia fall into categories:
    • neuromuscular disorders
    • oesophageal motility disorders
    • extrinsic pressure
    • intrinsic lesion
  • complications resulting from dysphagia include:
    • dehydration
    • malnutrition
    • bronchospasm
    • airway obstruction
    • aspiration pneumonia
    • chronic chest infection

Out of scope

  • Detailed specialist management of dysphagia

Assessment

Signs and Symptoms

Dysphagia will classically present as either:

  • difficulty in initiating a swallow - oropharyngeal dysphagia
  • the sensation that foods or liquids are being hindered in their passage from the mouth to the stomach - oesophageal dysphagia

Oropharyngeal dysphagia:

  • frequent accompanying symptoms include:
    • nasal regurgitation
    • coughing immediately, or shortly, after eating or drinking
    • nasal speech
    • diminished cough reflex
    • choking
    • difficulty chewing
    • drooling saliva
    • food dribbling from the mouth
    • dysarthria and diplopia may be features of an underlying neurological condition which causes dysphagia
    • halitosis
    • belching
  • other accompanying symptoms which indicate a specific neurological cause include:
    • hemiparesis following an earlier cerebrovascular accident (CVA)
    • ptosis of the eyelids
    • features of myasthenia gravis
    • features of Parkinson's disease
  • features of other neurological diseases such as:
    • cervical dystonia
    • cervical hyperostosis
    • Arnold-Chiari deformity
    • specific deficits of the cranial nerves involved in swallowing
    • recurrent chest infections

NB: Be aware that laryngeal penetration and aspiration can occur without concurrent coughing and/or choking.

Oesophageal dysphagia - accompanying symptoms may include:

  • chest pain
  • heartburn
  • regurgitation
  • weight loss
  • halitosis

History & Examination

The key objective during the patient's history and examination is to determine whether the dysphagia is oropharyngeal or oesophageal.

History

Make sure to ask about:

  • interval:
    • oropharyngeal dysphagia is characterised by:
    • difficulty in initiating swallowing
    • repeated attempts at swallowing
    • dysphagia within a second of starting to swallow
    • oesophageal dysphagia is characterised by dysphagia a few seconds after initiating a swallow
  • types of foods and/or liquids:
    • oropharyngeal dysphagia is usually suggested by problems swallowing liquids
    • oesophageal dysphagia is characterised by problems swallowing:
      • solids - suggests a mechanical oesophageal problem
      • solids and liquids - suggests an oesophageal motility problem
      • hot or cold foods - suggests oesophagitis
  • pattern:
    • progressive symptoms suggest an organic cause such as:
      • carcinoma
      • benign stricture
      • achalasia
    • a short (less than 3 months), progressive history suggests malignancy
    • intermittent symptoms may be due to:
      • oesophageal dsmotility
      • diverticula
      • web or ring
  • associated features:
    • weight loss - suggests an organic cause, e.g. carcinoma
    • cough:
      • commonly due to oropharyngeal dysphagia
      • may be due to achalasia when at night
      • rarely due to oesophagobronchial fistula
    • odynophagia often accompanies dysphagia in:
      • oesophagitis
      • achalasia
      • diffuse oesophageal spasm
    • slurred speech and weak voice
  • past medical history - make sure to check for a history of:
    • developmental problems
    • cerebrovascular disease
    • Parkinson's disease
    • Myasthenia gravis
    • other neurological diseases such as:
      • cervical dystonia
      • cervical hyperostosis
      • Arnold-Chiari deformity
    • Heartburn
    • Scleroderma
    • surgical history
    • voice loss and laryngitis
  • Medication history - ask about previous pharmacological treatments as these may be involved in the pathogenesis of dysphagia.
Examination
  • inspect the mouth and teeth or dentures
  • feel the supraclavicular nodes - may be palpable in patients with oesophageal cancer
  • look for signs of systemic diseases such as:
    • anaemia
    • systemic sclerosis
    • neurological

NB: Physical examination in oesophageal dysphagia is often of limited value.

Red Flags

  • The main concern with (oesophageal) dysphagia is to exclude malignancy
    • dysphagia has been shown to be a symptom in primary care populations that is highly predictive of cancer.
  • An urgent 2WW referral is indicated when dysphagia is:
    • of a short duration
    • for solids more than liquids
    • associated with progressive symptoms
    • associated with weight loss

Management

Oropharyngeal dysphagia

Causes of oropharyngeal dysphagia include:

  • mechanical and obstructive causes, e.g:
    • infections
  • thyromegaly
  • lymphadenopathy
  • Zenker's diverticulum
  • head and neck malignancies
  • neuromuscular disease:
    • pharyngeal disorders
    • bulbar palsy, e.g. motor neurone disease
    • myasthenia gravis
    • stroke
Oesophageal dysphagia

Causes of oesophageal dysphagia include:

  • oesophageal motility disorders:
    • achalasia
    • collagen vascular disease, e.g:
      • scleroderma
      • Raynaud's phenomenon
    • diffuse oesophageal spasm
    • presbyoesophagus
    • diabetes mellitus
    • Chagas' disease
  • extrinsic pressure:
    • mediastinal glands
    • goitre
    • enlarged atrium
  • intrinsic lesion:
    • foreign body
    • stricture:
      • peptic
      • corrosive
    • malignant:
      • carcinoma
      • melanoma (rare)
      • lymphoma
    • lower oesophageal ring
    • oesophageal web
    • pharyngeal pouch
  • Consider Barium swallow in elderly patients with long standing symptoms and no red flags.
Globus pharyngeus

Characterised by:

  • sensation of a constant 'lump' in throat
  • absence of true dysphagia or pain on swallowing
  • symptom not solely elicited by swallowing
  • Management:
    • consider a trial of proton pump inhibitors
    • if patient remains symptomatic, consider referring to:
      • ENT specialist
      • speech and language therapist (SLT)

Joint Formulary – Chapter 1 - Gastrointestinal

Referral

Referral Criteria

Refer to Gastroenterologist
  • Oesophageal causes of dysphagia
Refer to ENT
  • most oropharyngeal causes of dysphagia
  • for globus pharyngeus if symptoms persist following primary care management
Refer to Neurology
  • a neurological cause is suspected:
  • e.g. if patient exhibits:
    • hemiparesis following an earlier cerebrovascular accident (CVA)
    • cerebellar ataxia
    • ptosis of the eyelids
    • features of myasthenia gravis
    • features of Parkinson's disease
    • features of motor neurone disease
    • features of other neurological diseases such as:
    • cervical dystonia
    • cervical hyperostosis
    • Arnold-Chiari deformity
    • specific deficits of the cranial nerves involved in speech and swallowing

Referral Instructions

Referral to Gastroenterology
  • Refer using the e-Referral Service
    • Specialty: GI and Liver (Medicine and Surgery)
    • Clinic Type: Upper GI inc Dyspepsia
    • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N
Referral to ENT
  • Refer using the e-Referral Service
    • Speciality: Ear, Nose & Throat
    • Clinic Type: Throat (incl Voice/Swallowing)
    • Service – DRSS-Western-ENT- Devon CCG-15N
Referral to Neurology
  • Refer using the e-Referral Service
    • Specialty: Neurology
    • Clinic Type: Not Otherwise Specified
    • Service: DRSS-Western-Neurology-Devon CCG-15N

Referral Forms

DRSS Referral Proforma

Supporting Information

Pathway Group

This pathway was signed off by the NEW Devon CCG Western Locality Clinical Pathway Group.

Publication date: 10 February 2015

 

Home > Referral > Western locality > GI & Liver > Dysphagia

 

  • First line
  • Second line
  • Specialist
  • Hospital