What are the differentials and treatment options for a patient with difficulty swallowing (dysphagia)?

Dysphagia: Differential Diagnosis and Key History Points

When evaluating dysphagia, the single most critical historical distinction is whether the patient has difficulty with solids progressing to liquids (mechanical obstruction like tumor or stricture) versus difficulty with both solids and liquids from onset (motor disorder like achalasia). 1

Critical Initial History Questions

Timing and Progression Pattern

• Solids first, then liquids: Suggests mechanical obstruction (tumor, stricture, lower esophageal ring) 1
• Both solids and liquids from onset: Indicates motor disorder (achalasia, diffuse esophageal spasm) 1
• Intermittent versus progressive: Progressive symptoms favor malignancy or stricture; intermittent suggests rings or motility disorders 1

Location of Symptoms

• Oropharyngeal dysphagia (difficulty initiating swallow, within 1 second): Coughing/choking during meals, nasal regurgitation, wet vocal quality after swallowing, poor secretion management 1, 2, 3
• Esophageal dysphagia (retrosternal): Sensation of food sticking in chest, occurs several seconds after swallowing 1

Associated Red Flag Symptoms

• Weight loss: Malignancy until proven otherwise 4
• Odynophagia (painful swallowing): Infectious esophagitis (especially in immunocompromised), caustic injury, severe reflux esophagitis 1
• Recurrent pneumonia: Aspiration from oropharyngeal dysphagia 2, 4
• Hoarseness or voice changes: Laryngeal involvement or aspiration 1, 3

Major Differential Diagnoses by Category

Mechanical/Structural Causes

• Malignancy (esophageal, head/neck cancer): Progressive solid dysphagia, weight loss, older age 1
• Peptic stricture: History of GERD, progressive solid dysphagia 1
• Lower esophageal rings (Schatzki ring): Intermittent solid food dysphagia, often with meat or bread 1
• Eosinophilic esophagitis: Young males, food impaction episodes, atopic history 1
• Zenker's diverticulum: Regurgitation of undigested food, halitosis, gurgling in neck 5

Neuromuscular/Motor Disorders

• Stroke: Acute onset, other neurologic deficits, 30-64% of acute stroke patients develop dysphagia 1, 4
• Achalasia: Both solids and liquids from onset, regurgitation, chest pain 1
• Parkinson's disease: Bradykinesia of swallow, silent aspiration common 2, 4
• Dementia: Progressive cognitive decline with swallowing deterioration 1, 4
• Myasthenia gravis/Lambert-Eaton: Fatigable weakness, diplopia, fluctuating symptoms 6
• ALS: Progressive bulbar weakness, dysarthria, fasciculations 2

Infectious (Immunocompromised Patients)

• Candida esophagitis: Most common in HIV/immunosuppressed, odynophagia, white plaques 1
• Herpes simplex virus: Discrete ulcers, severe odynophagia 1
• Cytomegalovirus: Giant esophageal ulcers in advanced HIV 1

Iatrogenic/Medication-Related

• Post-intubation: Recent ICU stay, endotracheal tube trauma 1
• Post-radiation: Head/neck cancer treatment, progressive fibrosis 1
• Anticholinergic medications: Dry mouth, reduced esophageal motility 1
• Botulinum toxin complications: Recent cosmetic or therapeutic injections, can cause severe dysphagia and aspiration pneumonia 6

Age-Related Changes (Presbyphagia)

• Sarcopenia of swallowing muscles: Reduced tongue pressure, slower bolus transit 1
• Xerostomia: Reduced salivary flow, medication effects 1
• Slower mastication: Increased aspiration risk 1

Critical Physical Examination Findings

Oropharyngeal Assessment

• Drooling without ability to swallow: Positive sign of functional dysphagia 1
• Ability to spit into cup but claims inability to swallow: Functional dysphagia 1
• Wet vocal quality post-swallow: Aspiration or pooling in pharynx 1, 3
• Weak cough: Increased aspiration risk 1, 2

Neurologic Examination

• Cranial nerve deficits: CN V, VII, IX, X, XII involvement suggests neurogenic cause 7
• Gag reflex: Absence suggests neurologic impairment (though presence doesn't guarantee safe swallow) 7
• Tongue strength and coordination: Reduced in stroke, ALS, myasthenia 1

Neck Examination

• Cervical lymphadenopathy: Malignancy 7
• Thyromegaly: Extrinsic compression 7
• Surgical scars: Previous head/neck surgery 7

Diagnostic Approach Algorithm

Step 1: Determine Oropharyngeal vs. Esophageal

• Oropharyngeal signs (coughing, choking, nasal regurgitation, wet voice): Refer immediately to speech-language pathologist for instrumental evaluation (VFSS or FEES) 2, 3
• Esophageal symptoms (retrosternal sticking): Proceed to biphasic esophagram or endoscopy 1

Step 2: Instrumental Evaluation (Mandatory)

• Videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES): Required for all suspected dysphagia to identify specific impairment and guide treatment 2, 3
• Biphasic esophagram: 95% sensitivity for lower esophageal rings and strictures, superior to endoscopy for rings 1
• Endoscopy with biopsy: For suspected malignancy, eosinophilic esophagitis, or infectious esophagitis 1
• Esophageal manometry: For suspected achalasia or other motility disorders after barium study 1

Step 3: Timing of Evaluation

• Within 24 hours for hospitalized patients: Reduces aspiration pneumonia from 6.4% to 0% and mortality from 11% to 4.6% 2
• Before third day post-stroke: All stroke patients should be screened and comprehensively assessed 1
• Immediate referral: Patients with coughing/choking during meals, recurrent pneumonia, or progressive weight loss 2, 3

Common Pitfalls to Avoid

• Assuming no cough means safe swallow: Silent aspiration occurs in >70% of patients with aspiration detected on videofluoroscopy, especially with thin liquids 3, 8
• Relying on bedside evaluation alone: Clinical examination has insufficient sensitivity/specificity, particularly in elderly patients 1, 3
• Evaluating delirious patients: Futile and unreliable; wait until patient can participate 1
• Missing medication-induced dysphagia: Anticholinergics, botulinum toxin, and other agents commonly cause or worsen dysphagia 1, 6
• Delaying multidisciplinary team involvement: Early SLP, dietitian, and physician collaboration significantly improves outcomes 2, 3

Immediate Management Considerations

NPO Status

• Keep NPO if: Reduced consciousness, severe aspiration risk on screening, or awaiting instrumental evaluation 3, 8
• Modified diet: Thickened liquids reduce aspiration (thin < nectar-thick < honey-thick, p<0.001) 2, 8

Compensatory Strategies

• Chin-down (chin-tuck) posture: Eliminates aspiration in 77% of patients, most universally applicable maneuver 2
• Postural maneuvers: Head rotation, head tilt, lying down can eliminate aspiration in 77% during VFSS 2, 3

Pharmacologic Adjuncts

• ACE inhibitors: May reduce pneumonia risk in elderly stroke patients with dysphagia (18% to 7%, p=0.007) 2