What are the noninfectious causes and treatment options for dysphagia?

Noninfectious Causes and Treatment Options for Dysphagia

The most common noninfectious causes of dysphagia include neurological disorders, structural abnormalities, and functional disorders, with treatment requiring a targeted approach based on the underlying etiology. 1

Neurological Causes

• Stroke: Affects 19-65% of acute stroke patients, increasing pneumonia risk 3x 2

  • Treatment: Early screening by speech-language pathologist, videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES), restorative swallowing therapy, compensatory techniques 2

• Parkinson's Disease and Dementia: Common cause of oropharyngeal dysphagia 3

  • Treatment: Swallowing therapy, dietary modifications, postural adjustments

• Myositis: Affects proximal striated muscle, particularly the cricopharyngeus

  • Treatment: Cricopharyngeal-directed therapy (dilation, botulinum toxin injection, or myotomy) 2

Structural Causes

• Esophageal Strictures:

  • Malignant (27.3% of dysphagia cases) 4
  • Benign (8.6% of cases) 4
  • Treatment: Dilation, surgical intervention for intractable cases 2

• Eosinophilic Esophagitis (EoE): Increasingly prevalent allergic condition 5

  • Treatment: Medical therapy (steroids), dietary therapy, or esophageal dilation for strictures 2

• Schatzki's Ring: Found in 10.1% of dysphagia cases 4

  • Treatment: Dilation, acid suppression therapy

• Achalasia: Found in 5% of dysphagia cases 4

  • Treatment: Botulinum toxin injection, pneumatic dilation, surgical myotomy

Dermatological Causes

• Pemphigus Vulgaris: Can affect esophagus with or without skin manifestations

  • Treatment: Immunosuppressive therapy, supportive care 2

• Lichen Planus: Most common dermatologic condition affecting the esophagus

  • Treatment: Topical or systemic corticosteroids 2

Connective Tissue Disorders

• Systemic Sclerosis: Causes severe hypomotility and incompetent lower esophageal sphincter 2

  • Treatment: Proton pump inhibitors, prokinetic agents

• Mixed Connective Tissue Disease: Can affect both striated and smooth muscle of the esophagus 2

  • Treatment: Disease-modifying antirheumatic drugs, symptomatic management

Functional Disorders

• Functional Dysphagia: More often oropharyngeal than esophageal 2

  • Treatment: Behavioral therapy, speech therapy, addressing underlying psychological factors

• Globus Pharyngeus: Sensation of lump in throat without actual obstruction 2

  • Treatment: Reassurance, treatment of coexisting conditions (GERD, anxiety)

Treatment Approach Based on Type of Dysphagia

Oropharyngeal Dysphagia

1. Screening: Using validated tools by speech-language pathologist 1
2. Diagnostic Testing: VFSS or FEES to assess aspiration risk and swallowing mechanics 2, 1
3. Therapy Options:
   • Restorative techniques: Lingual resistance exercises, breath holds, effortful swallows 2
   • Compensatory techniques: Postural adjustments, sensory enhancement, texture modifications 2
   • Oral hygiene protocols to reduce aspiration pneumonia risk 1

Esophageal Dysphagia

1. Diagnostic Testing: Esophagogastroduodenoscopy with biopsies as first-line evaluation 5
2. Therapy Options:
   • Medication: Proton pump inhibitors for GERD-related dysphagia 5
   • Prokinetic agents like metoclopramide for motility disorders 6
   • Dilation for strictures, rings, or webs 2
   • Surgical intervention for refractory cases 2

Special Considerations

• Elderly Patients: Often have unrecognized dysphagia with high risk of aspiration and malnutrition 5

  • Consider early discussion about goals of care before invasive interventions

• Nutritional Support: Consider nasogastric feeding for severe dysphagia persisting beyond several days; percutaneous endoscopic gastrostomy if dysphagia persists beyond 2-3 weeks 1

• Medication Side Effects: Consider opioid-induced esophageal dysfunction in patients on pain medications 5

Pitfalls to Avoid

• Assuming dysphagia location correlates with pathology location; distal esophageal lesions can cause symptoms perceived in the throat 5
• Overlooking eosinophilic esophagitis; obtain esophageal biopsies during endoscopy even with normal-appearing mucosa 7
• Focusing only on symptom relief without addressing underlying inflammation in conditions like EoE 2
• Performing aggressive dilation in EoE patients without prior medical therapy, which increases perforation risk 2

By systematically evaluating the cause of dysphagia and implementing appropriate treatment strategies, clinicians can significantly improve patient outcomes and quality of life.