Dysphagia

Probability diagnosis

Functional (e.g. ‘express’ swallowing, psychogenic)

Tablet-induced irritation

Pharyngotonsillitis

GORD/reflux oesophagitis

Serious disorders not to be missed

Neoplasia/cancer:

• cancer of the pharynx, oesophagus (esp.) stomach

• extrinsic tumour

AIDS (opportunistic oesophageal infection)

Stricture, usually benign peptic stricture

Scleroderma

Neurological causes:

• pseudobulbar palsy

• multiple sclerosis

• motor neurone disease (amyotrophic sclerosis)

• Parkinson disease

Pitfalls (often missed)

Foreign body

Drugs (e.g. phenothiazines)

Subacute thyroiditis

Extrinsic lesions (e.g. lymph nodes, goitre)

Upper oesophageal web (e.g. Plummer–Vinson syndrome)

Eosinophilic oesophagitis

Radiotherapy

Achalasia

Upper oesophageal spasm (mimics angina)

Rarities (some):

• Sjögren syndrome

• aortic aneurysm

• aberrant right subclavian artery

• lead poisoning

• cervical osteoarthritis (large osteophytes)

• other neurological causes

• other mechanical causes

Masquerades checklist

Depression

Drugs

Thyroid disorder

Is the patient trying to tell me something?

Yes. Could be functional ?globus hystericus.

Key history

Analyse the nature of the symptom: difficulty in swallowing. Its origin is either oropharyngeal or oesophageal. A careful history includes a drug history and psychosocial factors.

Key examination

• Focus on the patient’s general features, mouth, oropharynx, larynx, neck (esp. lymphadenopathy and thyroid) and any abnormal neurological features especially cranial nerve function and muscle weakness disorders

Key investigations

Consider:

• FBE

• oesophageal manometry study (manometry)

• endoscopy ± barium swallow

• CXR.

The primary investigation in suspected pharyngeal dysphagia is a video barium swallow, while endoscopy is generally the first investigation in cases of suspected oesophageal dysphagia.

Diagnostic tips

• Dysphagia must not be confused with globus hystericus, which is the sensation of the ‘constant lump in the throat’ although there is no actual difficulty swallowing food.

• Mechanical dysphagia represents cancer until proved otherwise.

• Be careful of a change in symptoms in the presence of longstanding reflux (consider stricture or cancer).