Approach to Dysphagia

• Dysphagia : difficulty swallowing, could be oropharyngeal or esophageal.

Hx :

1. oropharyngeal : difficulty in initiating swallowing , choking, coghing, nasal regurgitation.
2. esophageal : inability to move food down esophagus.
3. age?
4. mechanical(solids) or neuromscular-motility disorder (solids+liquids, progressive or nonprogressive)?
5. intermittent (rings or spasm) or progressive (strictures or malignancies)?
6. heartburn (stricture or esophagitis)?
7. chest pain, wheezing, chronic cough, hoarseness (GERD)?
8. chest pain (spasm)
9. neuromuscular symptoms such as dysarthria, diplopia, muscle weaknesses, vertigo, nausea, vomiting, tremor, and ataxia (neuromascular diseases)?
10. change in wt (CA & achlasia ;weight loss) & appetite?
11. any comorbidities : immunocompromized (infectious esophagitis) , neuromascular diseases?
12. drugs Hx (pill-induced esophagitis)

Examination:

1. head and neck : masses, lymph nodes, or enlarged thyroid, Signs of prior surgery and radiotherapy , oral cavity (inspection of dentition or dentures, tongue, and oropharynx) & eye signs of thyrotoxicosis.
2. chest : signs of pneumonia due to aspiration.
3. A neurologic examination for cranial nerve dysfunction, neuromuscular disease, cerebellar dysfunction, or movement disorder.
4. collagen-vascular diseases signs : joint abnormalities, calcinosis, sclerodactyly, telangiectasia, and other findings.

Investigations:

• oropharygeal dysphagia :

1. modified barium swallow (MBS)
2. fiberoptic endoscopic evaluation of swallowing (FEES)

• esophageal dysphagia :

1. Barium swallow mainly for stricture detection & upper endoscopy is the gold standard for obstructive lesion are usually used intially.
2. esophageal manometry for diagnosis of motility disorders after obstructive lesions been excluded.