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Am Fam Physician. 2021;103(2):97-106

Related letter: Strangulation as a Cause of Dysphagia

Patient information: A handout on this topic is available at https://familydoctor.org/condition/dysphagia.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Many people occasionally experience difficult or impaired swallowing, but they often adapt their eating patterns to their symptoms and do not seek medical attention.1 Among those who do seek care, the most common causes are generally benign and self-limited, and serious or life-threatening conditions are rare. However, many older adults with progressive neurologic disease have significant but unrecognized dysphagia, which increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care. Understanding the basic pathophysiology of swallowing and the etiologies and clinical presentations of dysphagia allows family physicians to distinguish between oropharyngeal and esophageal pathology, make informed management decisions, and collaborate appropriately with specialists.

Clinical recommendationEvidence ratingComments
Patients younger than 50 years who have esophageal dysphagia and no other worrisome symptoms should undergo a four-week trial of acid suppression therapy before endoscopy is performed.9,26,27 BCAG and ACG guidelines; systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy
Patients with apparent oropharyngeal symptoms but a negative evaluation should be referred for EGD to rule out esophageal pathology.28 CRetrospective review of 3,668 consecutive patients; distal esophageal pathology was incorrectly perceived as arising from the neck or throat in 15% to 30% of cases
EGD is recommended for the initial assessment of patients with esophageal dysphagia; barium esophagography is recommended as an adjunct if EGD findings are negative.9,29,30 CCAG, STS, and WGO guidelines; expert consensus based on limited evidence and cost-analysis; EGD has greater sensitivity and specificity than barium esophagography, with greater cost-effectiveness
For accurate diagnosis of eosinophilic esophagitis, biopsies from normal-appearing mucosa in the midthoracic and distal esophagus should be requested for all patients with unexplained solid food dysphagia.15,17 BExpert consensus recommendation based on CAG, ACG, and AGA guidelines; early-stage eosinophilic esophagitis may not exhibit mucosal changes on endoscopy
Older patients with chronic illness or recent pneumonia should be screened for dysphagia; if it is present, the physician and patient should discuss goals of care.22,43 CExpert consensus on dysphagia as a geriatric syndrome
RecommendationSponsoring organization
Do not order “formal” swallow evaluation in stroke patients unless they fail their initial swallow screen.American Academy of Nursing
Do not recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer careful hand feeding.American Academy of Hospice and Palliative Medicine
American Geriatrics Society
AMDA – The Society for Post-Acute and Long-Term Care Medicine

Pathophysiology

Swallowing (deglutition) is a complex process involving voluntary and involuntary neuromuscular contractions coordinated to permit breathing and swallowing through the same anatomic pathway (Figure 1).2 Deglutition is commonly divided into oropharyngeal and esophageal stages. In the oropharyngeal stage, food is chewed and mixed with saliva to form a bolus of appropriate consistency in the mouth. With the initiation of the swallow, the bolus is propelled into the oropharynx by the tongue. Other structures simultaneously seal the nasopharynx and larynx to prevent regurgitation or aspiration, and the lower esophageal sphincter begins to relax. In the esophageal stage, the food bolus passes the upper esophageal sphincter and enters the esophageal body, where it is propelled by peristalsis through the midthoracic and distal esophagus and into the stomach through the now fully relaxed lower esophageal sphincter.3,4

Oropharyngeal Pathology

Oropharyngeal dysphagia is most commonly related to chronic neurologic conditions, particularly Parkinson disease, stroke, and dementia; it is not part of normal aging.5 It may be the first symptom of a neuromuscular disorder, such as amyotrophic lateral sclerosis or myasthenia gravis.6,7

Some chronic conditions, such as poor dentition, dentures, dry mouth (xerostomia), or medication adverse effects, may be poorly tolerated in patients who also have progressive oropharyngeal dysfunction. Tardive dyskinesia with choreiform tongue movements related to long-term antipsychotic use may cause decompensation in older adults; it also may cause dysphagia in younger patients.8 Chronic cough related to angiotensin-converting enzyme inhibitor use may interfere with swallowing or be mistaken for aspiration.

Structural abnormalities (e.g., Zenker diverticulum, cricopharyngeal bars or tumors, chronic infections with Candida or herpes virus) and extrinsic compression from cervical osteophytes or goiter can also interfere with normal swallowing (Table 1).514

Progressive chronic disease (geriatric syndrome)
Stroke
Parkinson disease
Alzheimer and other dementias
Sarcopenia
Neuromuscular disease
Amyotrophic lateral sclerosis
Myasthenia gravis
Multiple sclerosis
Dermatomyositis/polymyositis (myopathies)
Antipsychotic medications*
Structural causes
Head and neck cancers
Recent surgery or radiation for head and neck cancers (altered anatomy)
Chemoradiation-induced mucositis and edema (short term)
Zenker diverticulum
Cervical osteophytes
Lymphadenopathy
Goiter
Cricopharyngeal bar
Oral causes
Poor dentition or dentures
Dry mouth (i.e., xerostomia)
Medications causing dry mouth (e.g., alpha and beta blockers, angiotensin-converting enzyme inhibitors, anticholinergics, anti-histamines, anxiolytics, calcium channel blockers, diuretics, muscle relaxants, tricyclic antidepressants)
Antipsychotic medications*

Esophageal Pathology

Gastroesophageal reflux disease (GERD), functional esophageal disorders, and eosinophilic esophagitis are the most common causes of esophageal dysphagia5,15 (Table 21,5,1315). Less common causes include medications, obstructive lesions, and esophageal motility disorders.

Gastroesophageal reflux disease and esophagitis (30% to 40%)
Eosinophilic esophagitis*
Functional dysphagia
Functional esophageal disorders (20% to 30%)
Functional heartburn
Gastroesophageal reflux disease (nonerosive)
Globus pharyngeus
Reflux hypersensitivity
Medications (5%)
Pill esophagitis (direct irritation associated with ascorbic acid, bisphosphonates, ferrous sulfate, nonsteroidal anti-inflammatory drugs, potassium chloride, quinidine, and tetracyclines)
Reflux caused by decreased tone of lower esophageal sphincter (associated with alcohol, anticholinergics, benzodiazepines, caffeine, calcium channel blockers, nitrates, and tricyclic antidepressants)
Structural or mechanical conditions (5%)
Esophageal or peptic stricture (caused by erosive esophagitis)
Foreign body or food impaction (acute-onset dysphagia)
Malignancy (esophageal or gastric cancer, mediastinal mass with extrinsic compression)
Schatzki ring
Esophageal motility disorders (< 5%)§
Absent contractility
Achalasia
Distal esophageal spasm
Esophagogastric junction outflow obstruction
Hypercontractile (jackhammer) esophagus
Hypercontractile motility disorders
Opioid-induced esophageal dysfunction
Infections (< 5%)
Candida esophagitis
Cytomegalovirus esophagitis
Herpes simplex virus esophagitis
Rheumatologic conditions (< 5%)
Systemic sclerosis (scleroderma)

GASTROESOPHAGEAL REFLUX DISEASE

GERD and recurrent acid exposure result in changes ranging from submucosal inflammation and dysmotility to erosive esophagitis and stricture. Patients with GERD may experience dysphagia even in the absence of apparent mucosal damage.16

EOSINOPHILIC ESOPHAGITIS

Eosinophilic esophagitis is an increasingly common inflammatory condition triggered by food allergens.15 Chronic eosinophilic infiltration leads to progressive fibrosis, esophageal rings and furrows, and dysmotility.17

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