
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.
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.

Recommendation | Sponsoring 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
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.

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 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
Subscribe
From $145- Immediate, unlimited access to all AFP content
- More than 130 CME credits/year
- AAFP app access
- Print delivery available
Issue Access
$59.95- Immediate, unlimited access to this issue's content
- CME credits
- AAFP app access
- Print delivery available
Article Only
$25.95- Immediate, unlimited access to just this article
- CME credits
- AAFP app access
- Print delivery available