Dysphagia

Authored by , Reviewed by Dr Colin Tidy | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Difficulty Swallowing (Dysphagia) article more useful, or one of our other health articles.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Dysphagia is defined as difficulty in swallowing. It is usually associated either with pharyngeal or oesophageal disease[1]. There is a spectrum of possible aetiologies (see links in table under Aetiology, below), from self-limiting illness (eg, tonsillitis) to carcinoma. It may occur with odynophagia - painful swallowing.

Symptoms

NB: steady worsening of dysphagia over a few weeks in an older patient suggests malignancy.
  • As well as the feeling of food sticking in the gullet, patients with oesophageal disease may have other symptoms. These range from discomfort to severe pain, with the patient nearly always unable to locate the obstruction accurately.
  • Regurgitation, vomiting, coughing and choking are common.
  • Men with new onset of alarm symptoms (loss of weight with worsening dysphagia) have an increased likelihood of a diagnosis of cancer, especially in those aged over 65[2]. A positive predictive value of 9.0% has been found in this age group.
  • The most common lesions within the oesophagus are inflammatory strictures from reflux or tumours.
  • A long history of heartburn is usually associated with an inflammatory stricture.
  • In Westernised countries, eosinophilic oesophagitis is thought to affect between 40 and 55 per 100,000 population - similar to the numbers affected by Crohn's disease[3].
  • Idiopathic achalasia presents with dysphagia for solids and also regurgitation of a bland-tasting material that has never entered the stomach. It occurs in 1-2/100,000, most commonly seen in mid-adult life, and is caused by impaired neural control of the distal oesophagus[4].
  • Impairment of oropharyngeal swallowing function and abnormal laryngeal findings have been noted in patients with severe COVID-19 treated in intensive care units[5].
Obstructive
  • Gastro-oesophageal reflux ± stricture.
  • Eosinophilic oesophagitis.
  • Other oesophagitis (eg, infection).
  • Oesophageal cancer.
  • Gastric cancer.
  • Pharyngeal cancer.
  • Post-cricoid web
    (Paterson-Brown-Kelly syndrome).
  • Oesophageal rings.
  • Foreign body (acute).
Neurological
  • Cerebrovascular event or brain injury.
  • Achalasia.
  • Diffuse oesophageal spasm.
  • Syringomyelia or bulbar palsy.
  • Myasthenia gravis.
  • Multiple sclerosis.
  • Motor neurone disease.
  • Myopathy (dermatomyositis, myotonic dystrophy).
  • Parkinson's disease and other degenerative disorders.
  • Chagas' disease.
Others
  • Pharyngeal pouch.
  • Globus hystericus.
  • External compression
    (eg, mediastinal tumour, or associated with cervical spondylosis).
  • Calcinosis, Raynaud's disease, (o)esophageal dysmotility, sclerodactyly, telangiectasia (CREST) syndrome or scleroderma.
  • Oesophageal amyloidosis.
  • Inflammation - eg, tonsillitis, laryngitis.
  • FBC and erythrocyte sedimentation rate (ESR) should be taken.
  • Barium swallow and/or endoscopy with biopsy should usually be performed.
  • Laryngoscopic examination may be helpful if a pharyngeal cause is suspected.
  • In patients with severe COVID-19, the swallowing function should be assessed as a standard procedure, preferably at an early stage, before initiation of oral intake. Fibreoptic endoscopic evaluation of swallowing is preferred due to the high incidence of pooling of secretion and risk of silent aspiration[5].
  • MRI scanning may also be required before any surgery is considered - eg, if there is oesophageal carcinoma.
  • Endoscopic ultrasonography can assist with staging in oesophageal carcinoma.
  • Videofluoroscopy is the radiological investigation of choice when 'difficulty swallowing' rather than 'food sticking' is the presenting symptom and/or aspiration is suspected. However, fibreoptic endoscopic evaluation of swallowing (FEES) may be preferred if a less invasive approach is required, there are concerns about aspiration, repeated examinations are needed, or an assessment of swallowing using real food is required[6].
  • If the patient has no supra-oesophageal symptoms, negative barium swallow, negative FEES findings, and clinical evidence of oesophageal dysphagia, they should be referred to a gastroenterologist for a barium video-oesophagogram. This assesses both the anatomy (strictures or tumour) and motility function of the esophagus (such as achalasia).

When to refer[7]

If cancer is a possibility - offer urgent direct access upper gastrointestinal endoscopy (to be performed within two weeks)[7].

General

The patient may need to chew well or liquidise food.

There is insufficient evidence currently to support the efficacy of dietary modification, swallowing manoeuvres, surgical interventions, enteral feeding or intravenous immunoglobulin for the treatment of chronic neuromuscular conditions[8]. Patients with neurological problems (eg, cerebrovascular injury) may benefit from an early Speech and Language Therapy assessment[9].

Eosinophilic oesophagitis may be treated with dietary modification, topical steroids, leukotriene antagonists and other drugs, and endoscopic dilation[3].

Surgical

Definitive treatment depends on cause:

  • Strictures may be managed with endoscopic dilation (either using bougies or inflatable balloons).
  • If oesophageal carcinoma is diagnosed, staging will dictate whether curative surgery (for example, oesophagectomy) and chemotherapy are appropriate[10].
  • The overall five-year survival rate is 20-25% for all stages. Not surprisingly, lymph node involvement equates with a poorer prognosis. A study of 1,085 patients who underwent oesophagectomy showed a 4% operative mortality rate and a 23% survival rate. For patients who had pre-operative chemoradiotherapy, the prognosis improved to 48%[11].

  • In oesophageal carcinoma, palliative relief of dysphagia can be achieved with:
    • Repeated dilatation
    • Stent replacement[12]
    • Laser photocoagulation
    • Injection of sclerosants
  • Brachytherapy can be a useful alternative or adjunct.
  • Surgical myotomy and endoscopic injection of the sphincter with botulinum toxin are occasionally used for some aetiologies.

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Further reading and references

  1. Azer SA, Kshirsagar RK; Dysphagia

  2. Jones R, Latinovic R, Charlton J, et al; Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ. 2007 May 19334(7602):1040. Epub 2007 May 10.

  3. Park H; An Overview of Eosinophilic Esophagitis. Gut Liver. 2014 Nov8(6):590-597. Epub 2014 Nov 15.

  4. Patel DA, Kim HP, Zifodya JS, et al; Idiopathic (primary) achalasia: a review. Orphanet J Rare Dis. 2015 Jul 2210:89. doi: 10.1186/s13023-015-0302-1.

  5. Osbeck Sandblom H, Dotevall H, Svennerholm K, et al; Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study. PLoS One. 2021 Jun 416(6):e0252347. doi: 10.1371/journal.pone.0252347. eCollection 2021.

  6. Fattori B, Giusti P, Mancini V, et al; Comparison between videofluoroscopy, fiberoptic endoscopy and scintigraphy for diagnosis of oro-pharyngeal dysphagia. Acta Otorhinolaryngol Ital. 2016 Oct36(5):395-402. doi: 10.14639/0392-100X-829.

  7. Suspected cancer: recognition and referral; NICE guideline (2015 - last updated January 2021)

  8. Jones K, Pitceathly RD, Rose MR, et al; Interventions for dysphagia in long-term, progressive muscle disease. Cochrane Database Syst Rev. 2016 Feb 92:CD004303. doi: 10.1002/14651858.CD004303.pub4.

  9. O'Rourke F, Vickers K, Upton C, et al; Swallowing and oropharyngeal dysphagia. Clin Med (Lond). 2014 Apr14(2):196-9. doi: 10.7861/clinmedicine.14-2-196.

  10. Pennathur A, Gibson MK, Jobe BA, et al; Oesophageal carcinoma. Lancet. 2013 Feb 2381(9864):400-12. doi: 10.1016/S0140-6736(12)60643-6.

  11. Dubecz A, Gall I, Solymosi N, et al; Temporal trends in long-term survival and cure rates in esophageal cancer: a SEER database analysis. J Thorac Oncol. 2012 Feb7(2):443-7. doi: 10.1097/JTO.0b013e3182397751.

  12. Dai Y, Li C, Xie Y, et al; Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014 Oct 30(10):CD005048. doi: 10.1002/14651858.CD005048.pub4.

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