dysphagia

Dysphagia refers to subjective awareness of difficulty or obstruction during swallowing. It is a relatively common and increasingly prevalent clinical problem. Odynophagia is the term for painful swallowing.

Fluoroscopy is the mainstay of imaging assessment but manometry can help evaluate the esophageal motor pattern and lower esophageal sphincter function .

Epidemiology

Dysphagia is common in older age groups. Women are more prone to have dysphagia than men (80% vs 20%) .

Pathology

Dysphagia may be classified depending on the location of this sensation as oropharyngeal or substernal.

Dysphagia can be caused by functional or structural abnormalities of the oral cavity, pharynx, esophagus, and/or gastric cardia.

Oropharyngeal dysphagia

Oropharyngeal dysphagia occurs when a patient symptomatically localizes a sensation of blockage in the throat.

Functional causes
  • laryngeal penetration (when contrast seen entering the larynx at fluoroscopy) or aspiration (when contrast extends inferiorly through the true vocal), which are common with patients who have a history of neurologic disorders including stroke
  • cricopharyngeal muscle spasm
Structural causes
Substernal dysphagia

Substernal dysphagia occurs when a patient symptomatically localizes a sensation of discomfort or blockage between the thoracic inlet and the xiphoid process.

Functional causes
  • diffuse esophageal spasm (DES): characterized by multiple spontaneous and uncoordinated esophageal contractions which have the classic "corkscrew" appearance at esophagogram 
  • achalasia: characterized by esophageal dilatation with distal tapered beak-like narrowing at the gastro-esophageal junction
  • scleroderma: characterized by esophageal dilatation with a patulous gastroesophageal junction 
Structural causes 

Radiographic features

Fluoroscopy
  • modified barium swallow: used for the evaluation of swallowing mechanisms specifically for aspiration or penetration, this exam is usually performed in conjunction with a speech therapist to assess swallowing function and response to therapeutic strategies
  • barium swallow/esophagography: provides anatomic and functional information about the pharynx, esophagus, gastro-esophageal junction, and gastric cardia, including evaluation of esophageal motility and assessment for gastroesophageal reflux
  • barium tablet: may be used to detect subtle areas of esophageal narrowing
    • the tablet (of known 12.5 mm diameter) should be swallowed with a small amount of water and passage is observed at fluoroscopy; if the tablet becomes lodged in a particular location the patient should swallow a small amount of additional water and if the tablet remains lodged, a more detailed assessment should be performed
CT

Cross-sectional imaging may be used especially if there is a mass effect on the esophagus seen at esophagography or for evaluation of esophageal tumors.

Differential diagnosis

  • globus pharyngeus sometimes turns out to be the cause of the presentation, this is usually a diagnosis of exclusion