Dysphagia and odynophagia

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Chapter 2 DYSPHAGIA AND ODYNOPHAGIA

• A careful history will yield the likely diagnosis in 80% of cases.

• The site of bolus hold-up is not reliable if perceived in the neck.

• The most valuable investigations for oesophageal dysphagia are a barium swallow, endoscopy and oesophageal manometry.

• Endoscopy is essential to identify and biopsy the lesion but precise diagnosis may require additional radiography and manometry.

• Drugs likely to induced oesophageal ulceration include tetracycline antibiotics, potassium, iron supplements and bisphosphonates.

• Odynophagia almost always has an infective, inflammatory or corrosive aetiology.

• The three cardinal features of oesophageal dysmotility are dysphagia (for solids and liquids), chest pain and regurgitation.

• If endoscopy is suggestive of dysmotility, oesophageal manometry is the best way to confirm this.

• The typical features of neurogenic pharyngeal dysphagia are highly accurate.

• A multidisciplinary approach to the management of oropharyngeal dysphagia is important.

DYSPHAGIA

Taking the dysphagia history

A good history will elucidate the site and the general pathophysiological process in 80% of cases, and is vital before embarking on a focussed and cost effective utilisation of specific diagnostic techniques. Frequently, patients will describe food sticking or holding up either retrosternally or in the neck. However, more atypical symptoms can include regurgitation, a sense of fullness retrosternally and hiccup. Dysphagia is distinguished from odynophagia (pain on swallowing) by the perception of actual bolus hold up. The aims of the history are to:

• determine whether dysphagia is actually present (i.e. distinct from globus sensation and xerostomia)

• establish whether the site of the problem is oesophageal or pharyngeal

• distinguish between a structural and a motor abnormality.

Where does the food stick?

Retrosternal hold-up suggests that the disorder lies within the oesophagus. If the site of hold-up is in the neck, the pathology can lie either in the oesophagus or in the pharynx (Figure 2.1). Due to referred sensation, the site of perceived hold-up is above the suprasternal notch in 30% of cases where the actual hold-up is within the oesophageal body. Therefore, the next batch of questions aims to distinguish pharyngeal from oesophageal dysfunction.

FIGURE 2.1 Differentiating oesophageal disorders.

Is one or more of the four cardinal symptoms of pharyngeal dysfunction present?

The four cardinal symptoms of pharyngeal dysfunction are:

1. Delayed or absent oropharyngeal swallow initiation

2. Deglutitive post-nasal regurgitation or egress of fluid through the nose during swallowing

3. Deglutitive cough indicative of aspiration

4. The need to swallow repetitively to achieve satisfactory clearance of swallowed material from the hypopharynx.

Supportive but less specific symptoms of oropharyngeal dysphagia include: bolus hold-up in the neck, piecemeal swallows, oral spill or drooling, dysphonia, throat clearing, garbled voice and weight loss.

If one or more of these symptoms is/are present the dysphagia is probably oropharyngeal, either structural or neuromyogenic, and further history and investigation should proceed accordingly (see below).

If oesophageal dysphagia is suspected, the next step is to establish whether it is a structural or motor disorder (Tables 2.1 and 2.2).

TABLE 2.1 Structural oesophageal disorders causing dysphagia

• Peptic stricture

• Mucosal rings

– Lower (e.g. Schatzki’s ring)

– Multiple rings (e.g. eosinophilic oesophagitis)

– Cervical webs

• Corrosive strictures

– Caustic, pill-induced

• Oesophageal diverticula

• Benign tumours

• Extrinsic (vascular compression, tumour)

TABLE 2.2 Aetiology of pharyngeal dysphagia ^*

Structural	Neuromyogenic
• Tumour • Stenosis – Post-surgical – Radiation – Idiopathic • Zenker’s diverticulum • Cricopharyngeal bar • Web • Extrinsic compression

• Head trauma

• Parkinson’s disease

• Amyotrophic lateral sclerosis

• Multiple sclerosis

• Myasthenia gravis

• Myopathies (inflammatory, metabolic)

* Common causes. List not intended to be comprehensive.

Is the dysphagia for solids or liquids?

Typically the patient with a motor disorder (e.g. achalasia, diffuse spasm) will describe dysphagia for liquid and solids while structural disorders will cause dysphagia for solids only. As the calibre of the oesophagus narrows, the size of the bolus required to cause obstruction becomes progressively smaller.

If the problem is likely to be a structural oesophageal disorder, the following enquiry will define the likely cause.

How long has dysphagia been present; is it intermittent, is it progressive?

Longstanding dysphagia is compatible with a benign condition. Slowly progressive, longstanding dysphagia, particularly if reflux is or has been experienced, is highly suggestive of a peptic stricture. A short history of dysphagia particularly with rapid progression (weeks or months) and associated weight loss is highly suggestive of oesophageal cancer. Longstanding, intermittent, non-progressive dysphagia purely for solids is indicative of a fixed structural lesion such as a distal oesophageal ring or proximal oesophageal mucosal web.

What does the patient do when the bolus sticks?

Sipping water will frequently relieve obstruction due to a structural lesion causing solid bolus dysphagia. However, if the patient sips water in the context of a solid bolus impaction, this will result in immediate regurgitation of the water indicative of complete bolus obstruction. If the bolus is catching very high (e.g. at the cricopharyngeus) patients learn very quickly not to sip water as it results in immediate coughing and spluttering due to laryngeal penetration.

Does the patient regurgitate?

While regurgitation can be associated with solid bolus hold-up during a meal, spontaneous regurgitation between meals (generally fluid and ‘frothy’ saliva) is highly suggestive of dysmotility (see below).

If the problem is likely to be an oesophageal motility disorder, the following enquiry will define the likely cause.

The three cardinal features of oesophageal dysmotility are dysphagia (for solids and liquids), chest pain and regurgitation.

Regurgitation during the meal as well as spontaneous regurgitation between meals or at night (generally fluid and saliva) is highly suggestive of dysmotility. The regurgitated fluid/food is generally not noxious to taste (unlike reflux-related regurgitation).

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