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:
-
- 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.