Dysphagia

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.

• 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

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 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

Pathway Group

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

Publication date: 10 February 2015