Neuromuscular diseases
Cerebrovascular accident
Parkinson disease
Amyotrophic lateral sclerosis
Brainstem tumors
Bulbar poliomyelitis
Myasthenia gravis
Muscular dystrophies
Polymyositis
Metabolic myopathy
Amyloidosis
Systemic lupus erythematosus

Local mechanical lesions
Inflammation (pharyngitis, abscess, tuberculosis, radiation, syphilis)
Neoplasm
Congenital webs
Extrinsic compression (thyromegaly, cervical spine hyperostosis, adenopathy)
Radiation or caustic damage

Upper esophageal sphincter disorders
Primary cricopharyngeal dysfunction
Cricopharyngeal bar
Zenker diverticulum

Esophageal dysphagia
Motor disorders
Achalasia
Scleroderma
Diffuse esophageal spasm
Other spastic motor disorders
Other rheumatic conditions
Chagas disease

Intrinsic mechanical lesions
Benign stricture (peptic, lye, radiation)
Schatzki ring
CarcinomaEosinophilic esophagitis
Esophageal webs
Esophageal diverticula
Benign tumors
Foreign bodies

Extrinsic mechanical lesions
Vascular compression
Mediastinal abnormalities
Cervical osteoarthritis

Odynophagia
Mechanical
Trauma

Inflammatory
Pill-associated ulceration

Infectious
CMV, HSV, HIV

CMV, cytomegalovirus; HIV, human immunodeficiency virus; HSV, herpes simplex virus.

In patients with odynophagia, risk factors for opportunistic infection should be assessed and a careful medication history is warranted if pill esophagitis is a consideration.

Physical examination

The head and neck must be examined for sensory and motor function of the cranial nerves, masses, adenopathy, or spinal deformity. The patient should be observed swallowing water to visualize the co-ordinated symmetrical action of the neck and facial musculature. Evidence of systemic disease, including sclerodactyly, telangiectasias, and calcinosis in scleroderma, neuropathies or muscle weakness from generalized neuromuscular disease, and hepatomegaly or adenopathy due to esophageal malignancy should be sought. The presence of thrush suggests candidal infection as a cause of odynophagia.

Additional testing

If dysphagia is believed to be oropharyngeal, barium swallow radiography or endoscopy of the pharynx and esophagus may show occlusive lumenal lesions. Transnasal or peroral endoscopy also may reveal vocal cord paralysis, indicating neural dysfunction. Videofluoroscopy of mastication and swallowing of three different preparations (thin liquid, thick liquid, solid) is helpful in examining the co-ordination of the swallowing process in patients with suspected neuromuscular disease. In some instances, specialized manometry can reveal abnormal upper esophageal sphincter (UES) relaxations.

Endoscopy has become the preferred mode for assessing suspected esophageal dysphagia; however, contrast esophageal radiographic testing remains more sensitive for subtle structural lesions. Endoscopy is also optimal for identifying the etiology of odynophagia.

Differential diagnosis

Esophageal dysphagia

Obstructive esophageal lesions

Esophageal dysphagia is most commonly caused by structural lesions that physically impede bolus transit. Patients with esophageal strictures secondary to acid peptic damage may present with progressive dysphagia after a long history of heartburn. These strictures usually are located in the distal esophagus. More proximal strictures develop above the transition point to columnar mucosa in patients with Barrett esophagus. A Schatzki ring, a thin, circumferential mucosal structure at the gastroesophageal junction, causes episodic and nonprogressive dysphagia that often occurs during rushed ingestion of poorly chewed meat. Eosinophilic esophagitis should be considered in younger patients who present with intermittent solid food dysphagia or food impaction. Patients with squamous cell carcinoma also report progressive dysphagia, similar to peptic disease, but affected patients often are older and have had long-standing exposure to tobacco or alcohol and no prior pyrosis. Esophageal adenocarcinoma develops in areas of Barrett metaplasia resulting from prolonged gastroesophageal reflux. Other mechanical lesions (e.g. abnormal great vessel anatomy, mediastinal lymphadenopathy, and cervical vertebral spurs) can cause dysphagia.

Motor disorders of the esophagus

Primary and secondary disorders of esophageal motor activity represent the other main etiology of esophageal dysphagia. Primary achalasia is an idiopathic disorder characterized by esophageal body aperistalsis and failure of lower esophageal sphincter (LES) relaxation on swallowing with or without associated LES hypertension. Conditions that mimic primary achalasia include secondary achalasia, a disorder with identical radiographic and manometric characteristics caused by malignancy at the gastroesophageal junction or by paraneoplastic effects of a distant tumor, and Chagas disease, which results from infection with Trypanosoma cruzi. Other spastic esophageal dysmotilities, such as diffuse esophageal spasm, have also been associated with dysphagia. Systemic diseases (e.g. scleroderma and other rheumatic diseases) also cause dysphagia because of reduced rather than spastic esophageal motor function.

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