What is Dysphagia?
Dysphagia is a swallowing disorder characterized by difficulty in the passage of food or liquid from the mouth to the stomach, which can lead to serious complications including aspiration pneumonia, malnutrition, and death if not diagnosed early. 1
Definition and Classification
Dysphagia can be classified into two main types:
Oropharyngeal dysphagia: Difficulty initiating swallowing, affecting the oral cavity, pharynx, and upper esophageal sphincter
- ICD-10 codes: R13.0 (inability to swallow), R13.11 (oral phase dysphagia), R13.12 (oropharyngeal dysphagia), R13.13 (pharyngeal dysphagia) 1
Esophageal dysphagia: Sensation that food stops in the chest or substernal area 2
Prevalence and Impact
Dysphagia is highly prevalent, particularly in specific populations:
- Affects up to 22% of adults in primary care settings 1
- More common in older adults, with adults over 65 accounting for two-thirds of all cases 1
- Prevalence among independently living older persons: 16% in 70-79 year olds, 33% in those over 80 1
- 51% of institutionalized older persons are affected 1
- Up to 47% of frail elderly patients hospitalized for acute illness 1
Causes of Dysphagia
Neurological Disorders
- Stroke: Affects at least 50% of patients, leading to three-fold increased risk of aspiration pneumonia 1, 3
- Parkinson's disease: Major risk factor for pneumonia development 1, 3
- ALS: Up to 30% present with swallowing impairment at diagnosis; virtually all develop dysphagia as disease progresses 1, 3
- Multiple sclerosis: Occurs in more than one-third of patients 1, 3
- Myasthenia gravis: 15% present with dysphagia initially; over 50% develop it as disease progresses 1, 3
- Inflammatory myopathies: Affects 20% in dermatomyositis, 30-60% in polymyositis, 65-86% in inclusion body myositis 1, 3
Structural Causes
- Pharyngeal or cricopharyngeal strictures 3
- Oropharyngeal tumors 3
- Posterior pharyngeal diverticulum 3
- Cervical webs 3
- Thyroid nodules causing compression 3
- Cricopharyngeal bars 3
- Cervical osteophytes or skeletal hyperostosis 3
Other Causes
- Upper esophageal sphincter dysfunction 3
- Presbyphagia (age-related changes in swallowing physiology) 1, 3
- Post-cervical spine surgery 3
- Critical illness polyneuropathy (70-80% of patients requiring prolonged mechanical ventilation) 1
Clinical Presentation
Patients with dysphagia typically present with:
- Food sticking in the throat
- Globus sensation
- Coughing/choking during swallowing
- Nasal-quality voice
- Nasal regurgitation
- Food dribbling
- Difficulty initiating swallow 3
- Reflexive cough during eating (74% sensitivity and specificity for aspiration in neurologically impaired patients) 3
Diagnostic Evaluation
Imaging studies are complementary to endoscopy and manometry in dysphagia evaluation:
Fluoroscopy: Primary imaging modality of choice 1
CT of the neck with IV contrast: Useful for assessing position of surgical hardware and postoperative anatomy 3
Complications
Untreated dysphagia can lead to:
- Aspiration pneumonia 1, 3
- Malnutrition and dehydration 1, 3, 4
- Weight loss 1
- Reduced quality of life 1, 3
- Increased mortality 1
- Insufficient medication intake 1
Management Considerations
Management depends on the underlying cause but generally includes:
- Texture-modified diets and thickened fluids to ensure safe swallowing 1, 3
- Behavioral and rehabilitation treatments for neurogenic dysphagia 1
- Enteral nutrition therapy (via PEG) for patients unable to meet nutritional needs orally 1
Important Clinical Considerations
- Silent aspiration (aspiration without protective cough reflex) occurs in 55% of patients who aspirate 1
- Aging itself does not typically cause clinically significant dysphagia but is associated with increased prevalence of neuromuscular and degenerative disorders that can cause dysphagia 1
- In patients with unexplained oropharyngeal dysphagia, a complete examination of the esophagus should be performed, as 68% of patients with complaints of dysphagia for solids have abnormal esophageal transit 3