121

Dysphagia
Jeffrey B. Palmer, MD, and Koichiro Matsuo, DDS, PhD

DEFINITION
Dysphagia generally refers to any difficulty with swallowing including occult or asymptomatic
impairments. It is a common problem, affecting one third to one half of all stroke patients 1 and
about one sixth of elderly individuals.2 It is frequent in head and neck cancer, traumatic brain
injury, degenerative disorders of the nervous system, gastroesophageal reflux disease, and
inflammatory muscle disease (Table 121-1). Dysphagia is classified according to the location of
the problem as oropharyngeal (localized to the oral cavity of pharynx, not just the oropharynx) or
esophageal. It may also be classified as mechanical (due to a structural lesion of the foodway) or
functional (caused by a physiologic abnormality of foodway function).3
Sudden onset is suggestive of stroke. Concomitant limb weakness suggests a neurologic or
neuromuscular disorder. Medication-induced dysphagia is commonly over-looked. Medications
that impair level of consciousness (such as sedatives and tranquilizers), have anticholinegic
effects (tricyclics, propantheline), or can damage mucous membranes (nonsteroidal antiinflammatory drugs, aspirin, quinidine) may also cause dysphagia. 4
SYMPTOMS
The most common symptoms of dysphagia are coughing or choking during eating 5 and the
sensation of food sticking in the throat or chest.3 Some of the many symptoms and signs of
dysphagia are listed in the Table 121-2. A history of drooling, significant weight loss, or
recurrent pneumonia suggests that the dysphagia is severe. The history is most useful for
identification of esophageal dysphagia; the complaint of food sticking in the chest is usually
associated with an esophageal disorder. In contrast, the complaint of food sticking in the throat
has little localizing value and is often caused by an esophageal disorder. Coughing and choking
during swallowing suggest an oropharyngeal origin and may be elicited by aspiration
(penetration of material through the vocal folds and into the trachea). However, some patients
have impaired cough reflexes, resulting in silent aspiration (without cough). 5,6 Silent aspiration
occurs in 28% to 94%, depending on the population of patients. 6-8 Patients with neurologic
disorder have a higher incidence of silent aspiration. Pain on swallowing (odynophagia) may
occur transiently in pharyngitis, but persistent pain is unusual and is suggestive neoplasia. Heart
burn is a nonspecific complaint that is usually not associated with swallowing but occurs after
meals. Heart burn may occur in gastroesophageal reflux disease, but a more specific symptom of

gastroesophageal reflux disease is regurgitation of sour or bitter-tasting material into the throat
after eating.
PHYSICAL EXAMINATION
An examination of the oral cavity and neck may identify structural abnormalities, weakness, or
sensory deficits. The finding of dysarthria (abnormal articulation of speech) or dysphonia
(abnormal voice quality) is often associated with oropharyngeal dysphagia. However, the
examination is primarily useful for finding evidence of underlying neurologic, neuromuscular, or
connective tissue disease. The examination should always include trial swallows of water.9-11
During the swallow, there should be prompt elevation of the hyoid bone and larynx. Changes in
voice quality or spontaneous coughing after swallowing suggest pharyngeal dysfunction. The
history and physical examination are limited in their ability to detect and to characterize
dysphagia, so instrumental studies are usually necessary.
Neurologic examination is important in the evaluation of dysphagic individuals because
neurologic disorders commonly cause dysphagia. Disorders of either upper or lower motor
neuron may produce dysphagia. The findings of atrophy or fasciculations of the tounge or palate
suggest lower motor neuron dysfunction of the brainstem motor nuclei. In contrast to the
prevailing wisdom, the gag reflex is not strongly predictive of the ability to swallow. It may be
absent in normal individuals and normal in individuals with severe dysphagia and aspiration.
TABLE 121-1 Selected Causes of Oral and Pharyngeal Dysphagia
Neurologic Disorders
Structural Lesions
Connective Tissue
and Stroke
Diseases
Cerebral Infarction
Thyromegaly
Polymyositis
Brainstem Infarction
Cervical Hyperostosis
Muscular Dystrophy
Intracranial Hemorrhage Congenital Web
Psychiatric Disorders
Parkinson Disease
Zenker Diverticulum
Psychogenic Dysphagia
Multiple Sclerosis
Caustic Ingestion
Amyotrophic Lateral
Neoplasm
Sclerosis (ALS)
Post-ablative Surgery
Poliomyelitis
Radiation Fibrosis
Miasthenia Gravis
Dementias
TABLE 121-2 Symptoms and Signs of Dysphagia
Oral or Pharyngeal Dysphagia
Coughing or choking with swallowing
Difficulty with initiation of swallowing
Food sticking in the throat
Drooling
Unexplained weight loss

Change in dietary habits

Recurrent pneumonia
Change in voice of speech
Nasal regurgitation
Dehydration
Esophageal Dysphagia
Sensation of food sticking in the chest or throat
Oral or pharyngeal regurgitation
Drooling
Unexplained weight loss
Change in dietary habits
Reccurent pneumonia
Dehydration
FUNCTIONAL LIMITATIONS
These depend on the nature and severity of the dysphagia. Many individuals modify their diets to
eliminate foods that are difficult to swallow. Some require inordinate amounts of time to
consume a meal. In severe cases, tube feeding is necessary. These alterations in the ability to eat
a meal may have profound effect on psychological and social function. 14 Interaction with family
and friends often centers on mealtime-family dinners, going out for a drink or for dinner,
coming over for a snack or for dessert. Difficulty in eating a meal may disrupt relationships
and result in social isolation. Some patients may require supervision during meals or feel unsafe
when they eat alone, causing further disruption of social and vocational function.
DIAGNOSTIC TESTING
Because the mechanics of swallowing are largely invisible to the naked eye, diagnostic studies
are commonly needed. The sine qua non for diagnosis of oropharyngeal swallowing disorders is
the videoflourographic swallowing study (VFSS).15 In this test, the patients eats and drinks a
variety of solids and liquids combined with barium while images are recorded with
videoflourography (radiographic video taping). The VFSS is usually performed jointly by a
physician (physiatrist or radiologist) and a speech-language pathologist. A unique benefit of the
VFSS is that therapeutic techniques (such as modification of food consistency, body position, or
respiration) can be tested and their effects on swallowing observed during the study. A routine
barium swallow study is frequently sufficient if the problem is clearly esophageal.
If a VFSS cannot be performed because of the physical limitation of the patient, the fiberoptic
endoscopic evaluation of swallowing is useful to visualize the anatomy of the pharynx and
larynx and vocal fold function during eating with no x-ray exposure. 16 It is also highly sensitive
for detection of aspiration8; but it does not visualize essential aspects of swallowing, such as the

oral and esophageal stage of swallowing including opening of the upper esophageal sphincter,
elevation of the larynx, and contraction of the pharynx.
In case of esophageal dysphagia, esophagoscopy is frequently necessary to detect mucosal lesion
or masses. Biopsy is indicated when mucosal abnormalities are detected. Manometry is useful
for detection and characterization of motor disorders of the esophagus. Electromyography is
indicated when neuromuscular disease is suspected and is useful for detection of lower motor
neuron dysfunction of the larynx and pharynx.
TREATMENT
Initial
The treatment of dysphagia depends on its causes and mechanism. Common treatments are
listed in Table 121-3. Whenever possible, initial treatment should be directed at the underlying
disease process; for example, levodopa for Parkinson disease, or steroids for polymyositis.
Esophageal dysphagia necessitates evaluation and treatment by a gastroenterologist. When no
therapy exist for the underlying disease or the therapy is ineffective or contraindicated,
rehabilitative strategies are appropriate. Patients and their family members are encouraged to
learn the Heimlich manuever; this is important because airway obstruction is potentially fatal.
Differential Diagnosis
Myocardial ischemia
Globus sensation
Heartburn due to gastroesophageal reflux disease
Indirect aspiration (aspiration of refluxed gastric content)

Rehabilitation
Many patients benefit from a structured swallowing therapy provided by a speech-language
pathologist, including instruction and supervision about diet, compensatory manuevers, and
exercise.17 The goals of therapy are to reduce aspiration, to improve the ability to eat and drink,
and to optimize nutritional status. Therapy is individualized according to the patients specific
anatomic and structural abnormalities and the initial responses to treatment trials observed at the
bedside or during the VFSS.18
Table 121-3 Principal Treatments of Selected Disorders Affecting Swallowing
Problems
Amvotrophic lateral sclerosis

Principal Treatments
Dietary modification
Compensatory manuevers

Carcinoma of esophagus
Gastroesophageal reflux disease

Parkinson disease,
myasternia gravis

polimyositis,

Esophageal stricture or web

Stroke multiple sclerosis

Counceling and advance directives

Esophagectomy
Dietary modification
No eating at bedtime
Pharmacologic therapy
Smoking cessation
Pharmacologic treatment of underlying disease
(dietary modification, compensatory manuevers,
and dysphagia therapy only if neccesary).
Dilatation
Dietary modification
Compensatory manuevers
Dysphagia therapy

A fundamental principle of rehabilitation is that the best therapy for any activity is the activity
itself; swallowing is generally the best therapy for swallowing disorders, so the rehabilitation
evaluation is directed at identification of circumstances for safe and effective swallowing for
each individual patient.
Diet modification is a common treatment of dysphagia.19,20 Patients vary in ability to swallow
thin and thick liquids, and that determination is usually best made by VFSS. A patient can
usually receive adequate oral hydration with either thin (e.g., water or apple juice) or thick
liquids (e.g., apricot nectar, tomato juice). Rarely, a patient may be limited to pudding
consistency if thin and thick liquids are freely aspirated. Most patients with significant
dysphagia are unable to safely eat meats or similarly though foods and require a mechanical soft
diet. A pureed diet is recommended for patients who exhibit oral preparatory phase difficulties,
pocket food in the buccal recesses (between the teeth and the cheek), or have significant
pharyngeal retention with chewed solid foods. Maintenance of oral feeding often requires
compensatory techniques to reduce aspiration or to improve pharyngeal clearance. A variety of
behavioral techniques are used , including modifications of posture, head position (Fig. 121-1), 2122
and respiration, 23 as well as specific swallow manuevers.24-26
Execise therapy for dysphagia is indicated when the problem is related to weakness of the
muscles of swalowing.27 The choice of exercises must be individualized according to the
physiologic assessment. The full range of exercises is beyond the scope of this chapter, but
several example illustrate the principles.

Tongue weakness can be treated with lingual resistance exercise.28

Strengthening of the anterior suprahyoid muscles is useful when the upper esophageal
sphincter opens poorly. Flexing the neck against gravity while lying supine can strengthen
these muscles (Fig. 121-2).29,30
Vocal fold adduction exercises may be useful in cases of aspiration due to weakness of these
muscles. These exercises are done on a daily basis whenever possible.

Procedures
VFSS functions as both a diagnostic and a therapeutic procedures for dysphagia, especially
otopharyngeal dysphagia, because it can be used to test the effectiveness of modifying food
consistency and other compensatory techniques.31 Endoscopy with dilatation of the esophagus is
often indicated in cases of partial esophageal obstruction due to stricture or web. Dilatation is
also appropriate in stenosis of the upper esophageal sphincter. Endoscopy can also be used for
biofeedback, especially to demonstrate movements of the larynx during swallowing manuevers.
Electromyography is also used for biofeedback. Activities of the infrahyoid and suprahyoid
muscles are recorded with surface electrodes during swallowing therapy. Biofeedback itself is
not a dysphagia therapy but can be a useful adjunct to therapy. Surface electrical stimulation on
the submental or anterior cervical muscles is a controversial new treatment of dysphagia. There
is little evidence for its safety and efficacy.32-34
Surgery
Surgery is rarely indicated in the care of patients with oral pharyngeal dysphagia. The most
common procedure for pharyngeal dysphagia is cricopharyngeal myotomy, during which the
upper esophageal sphincter is disrupted to reduce the resistance of the pharyngeal outflow tract.
However, the effectiveness of myotomy is highly controversial. 35 Esophagectomy may be
necessary in case of esophageal cancer or obstructive strictures. Feeding gastrotomy (usually
percutaneous endoscopic gastrotomy) is indicated when the severity of the dysphagia makes it
impossible for adequate alimentation or hydration to be obtained orally, although intravenous
hydration or nasogastric tube feeding may be sufficient on a time-limited basis. 36 Orogastric tube
feedings have been used successfully by patients who have absent gag reflexes and can tolerate
intermitten oral catheterization.

POTENTIAL DISEASE COMPLICATION

Severe dysphagia may result in aspiration pneumonia, airway obstruction, bronchiectasis,
dehydration, or starvation37 and is potentially fatal. Severe dysphagia often causes social
isolation because of the inability to consume a meal in the usual manner. This may lead to
depression, sometimes severe. Suicide has been reported.

POTENTIAL TREATMENT COMPLICATIONS

The VFSS is safe and well tolerated. Prescription of a modified diet often means the substition
of thick for thin liquids. Some patients find these unpalatable and reduce fluid intake to the point
of dehydration and malnutrition. Failure to reevaluate patients in a timely manner may lead to
unnecessary prolongation of dietary restrictions, increasing the risk of malnutrition and adverse
psychological effects of dysphagia. Dilatation of the esophagus or sphincters may result in

perforation, but this complication is uncommon. Percutaneous endoscopic gastrostomy may

have direct or indirect sequelae. Direct sequelae, such as pain, infection, and obstruction of the
feeding tube, are common. Percutaneous endoscopic gastrotomy tube feeding may promote
aspiration pneumonia in individuals with severe gastroesophageal reflux disease.

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