Oropharyngeal Dysphagia

Processes that affect the mouth, hypopharynx, and upper esophagus produce a distinctive type of dysphagia. The patient often is unable to initiate a swallow and repeatedly has to attempt to swallow. Patients frequently describe coughing or choking when they attempt to eat. The inability to propel a food bolus successfully from the hypopharyngeal area through the upper esophageal sphincter (UES) into the esophageal body is called oropharyngeal, or transfer, dysphagia. The patient is aware that the bolus has not left the oropharynx and locates the site of symptoms specifically to the region of the cervical esophagus. Dysphagia that occurs immediately or within one second of swallowing suggests an oropharyngeal abnormality. At times, a liquid bolus may enter the trachea or nose rather than the esophagus. Some patients describe recurrent bolus impactions that require manual dislodgment. In severe cases, saliva cannot be swallowed, and the patient drools. Abnormalities of speech such as dysarthria or nasal speech may be associated with oropharyngeal dysphagia. Oral pathology should be considered as well. For example, poor teeth or poorly fitting dentures may disrupt mastication and result in an attempt to swallow an overly large or poorly chewed bolus. Loss of salivation—caused by medications, radiation, or primary salivary dysfunction—may result in a bolus that is difficult to swallow.

Recurrent bouts of pulmonary infection may reflect spillover of food into the trachea because of inadequate laryngeal protection. Hoarseness may result from recurrent laryngeal nerve dysfunction or intrinsic muscular disease, both of which cause ineffective vocal cord movement. Weakness of the soft palate or pharyngeal constrictors causes dysarthria and nasal speech as well as pharyngonasal regurgitation. Swallowing associated with a gurgling noise may be described by patients with Zenker’s diverticulum. Finally, unexplained weight loss may be the only clue to a swallowing disorder; patients avoid eating because of the difficulties encountered. Potential causes of oropharyngeal dysphagia are shown in Table 12-1.

Table 12-1 Causes of Oropharyngeal Dysphagia

* Any disease that affects striated muscle or its innervation may result in dysphagia.

† Many manometric disorders (hypertensive and hypotensive UES, abnormal coordination, and incomplete UES relaxation) have been described, although their true relationship to dysphagia is often unclear.

After an adequate history is obtained, the initial test is a carefully conducted barium radiographic examination, which is optimally performed with the assistance of a swallowing therapist (modified barium swallow). If the study is normal with liquid barium, the examination is repeated after the patient is fed a solid bolus in an attempt to bring out the patient’s symptoms and thereby aid in localizing any pathology. If the oropharyngeal portion of the study is normal, the remainder of the esophagus should be examined. This single test usually identifies the problem and directs initial therapy.

Esophageal Dysphagia

Most patients with esophageal dysphagia localize their symptoms to the lower sternum or, at times, the epigastric region. A smaller number of patients will describe a sensation in the suprasternal notch or higher, even though the bolus stops in the lower esophagus. Esophageal dysphagia frequently can be relieved by various maneuvers, including repeated swallowing, raising the arms over the head, throwing the shoulders back, and using the Valsalva maneuver. Motility disorders or mechanical obstructing lesions can cause esophageal dysphagia. To clarify the origin of symptoms of esophageal dysphagia, the answers to three questions are crucial:

On the basis of these answers, distinguishing the several causes of esophageal dysphagia (Table 12-2) as a mechanical or a neuromuscular defect and postulating the specific cause are often possible (Fig. 12-1).

Table 12-2 Common Causes of Esophageal Dysphagia

Figure 12-1. Diagnostic algorithm for patients with dysphagia. For details of the approach to each type of dysphagia, see the text and tables. Less specific motility disorders include nutcracker esophagus, diffuse esophageal spasm, and other disorders of ineffective esophageal motility.

(Modified from Castell DO, Donner MW. Evaluation of dysphagia: A careful history is crucial. Dysphagia 1987; 2:65-71.)

Patients who report dysphagia with solids and liquids are more likely to have an esophageal motility disorder than mechanical obstruction. Achalasia is the prototypical esophageal motility disorder in which, in addition to dysphagia, many patients complain of bland regurgitation of undigested food, especially at night, and of weight loss. By contrast, patients with spastic motility disorders such as diffuse esophageal spasm may complain of chest pain and sensitivity to hot or cold liquids. Patients with scleroderma of the esophagus usually have Raynaud’s phenomenon and severe heartburn. In these patients, mild complaints of dysphagia can be caused by a motility disturbance or esophageal inflammation, but severe dysphagia almost always signals the presence of a peptic stricture (see Chapters 35 and 43).

In patients who report dysphagia only after swallowing solid foods and never with liquids alone, a mechanical obstruction is suspected. A luminal obstruction of sufficiently high grade, however, may be associated with dysphagia for solids and liquids. If food impaction develops, the patient frequently must regurgitate for relief. If a patient continues to drink liquid after the bolus impaction, large amounts of that liquid may be regurgitated. In addition, hypersalivation is common during an episode of dysphagia, thereby providing even more liquid to regurgitate. Episodic and nonprogressive dysphagia without weight loss is characteristic of an esophageal web or a distal esophageal (Schatzki) ring. The first episode typically occurs during a hurried meal, often with alcohol. The patient notes that the bolus of food sticks in the lower esophagus; it often can be passed by drinking large quantities of liquids. Many patients finish the meal without difficulty after the obstruction is relieved. The offending food frequently is a piece of bread or steak—hence the term steakhouse syndrome.⁷ Initially, an episode may not recur for weeks or months, but subsequent episodes may occur frequently. Daily dysphagia, however, is likely not caused by a lower esophageal ring (see Chapter 41).

If solid food dysphagia is clearly progressive, the differential diagnosis includes peptic esophageal stricture and carcinoma. Benign esophageal strictures develop in some patients with GERD. Most of these patients have a long history of associated heartburn. Weight loss seldom occurs in patients with a benign lesion, because these patients have a good appetite and convert their diet to high-calorie soft and liquid foods to maintain weight (see Chapter 43). Patients with carcinoma differ from those with peptic stricture in several ways. As a group, the patients with carcinoma are older and present with a history of rapidly progressive dysphagia. They may or may not have a history of heartburn, and heartburn may have occurred in the past but not the present. Most have anorexia and weight loss (see Chapter 46). True dysphagia may be seen in patients with pill, caustic, or viral esophagitis; however, the predominant complaint of patients with these acute esophageal injuries is usually odynophagia. Patients may present with food bolus impaction, and eosinophilic esophagitis should be considered in the differential diagnosis of all patients (particularly those who are young) who present with dysphagia (see Chapter 27).⁸

After a focused history of the patient’s symptoms is obtained, a barium radiograph, including a solid bolus challenge, is often advocated as the first test. Alternatively, many experts have advocated endoscopy as the first test, especially in patients with intermittent dysphagia for solid food suggestive of a lower esophageal ring or with pronounced reflux symptoms. The choice of the initial test should be based on local expertise and the preference of the individual health care provider. If the barium examination demonstrates an obstructive lesion, endoscopy is usually done for confirmation and biopsy. Endoscopy also permits dilation of strictures, rings, and neoplasms. Empirical dilation of the esophagus is often performed in patients with a suggestive history and normal endoscopic examination,⁹ but the safety and efficacy of this approach have been questioned.¹⁰ If the barium examination is normal, esophageal manometry is often performed to look for a motility disorder. Some patients with reflux symptoms and dysphagia, a normal barium study or endoscopy, or both, will respond to a trial of gastric acid suppressive therapy.