Dysphagia can be classified as either oropharyngeal or esophageal. Initial evaluation of oropharyngeal and esophageal dysphagia differs, making their distinction important. In most cases a comprehensive examination and a careful history are sufficient to guide appropriate evaluation.
The diagnosis and treatment of oropharyngeal dysphagia will be reviewed here, while esophageal dysphagia is presented separately. (See "Evaluation of dysphagia in adults".) A guideline issued by the American Gastroenterological Association (AGA) on this topic is also available (algorithm 1). The AGA guideline for oropharyngeal dysphagia , as well as other AGA guidelines, can be accessed through the AGA web site at http://www.gastro.org/practice/medical-position-statements. The physiology of normal swallowing, and the pathogenesis and clinical manifestations of oropharyngeal dysphagia are discussed separately. (See "Pathogenesis and clinical manifestations of oropharyngeal dysphagia".)
HISTORY AND PHYSICAL EXAMINATION
A careful history and physical examination can usually distinguish between an esophageal and oropharyngeal cause of dysphagia (algorithm 2) . Furthermore, they can often predict the cause of oropharyngeal dysphagia, which should be confirmed by specific testing .
History — For most patients, specific clues in the history can help establish the cause of the dysphagia (table 1):
- Patients with any cause of oropharyngeal dysphagia complain of symptoms immediately upon swallowing; in contrast, the onset of symptoms after swallowing is delayed in patients with esophageal dysphagia. Patients with oropharyngeal dysphagia point toward the cervical region when asked to identify the site of their symptoms; however, because the interpretation of visceral innervation is imprecise, dysphagia related to distal esophageal disease, such as a peptic stricture, may sometimes be felt in the suprasternal notch.
- Older patients presenting with oropharyngeal dysphagia, particularly those with a history of alcohol abuse, smoking, or weight loss, should raise concern about a malignant cause. Referred pain, such as otalgia (ear pain), may indicate a hypopharyngeal lesion . Referred otalgia is not just a symptom of hypopharyngeal cancer but can also occur at other sites such as the larynx, pharynx, and base of the tongue.
- Patients who have difficulty transferring food from the mouth to the pharynx will often reposition their body to optimize alignment of the bolus for presentation to the pharynx. Such patients may report extending their arms and neck during swallowing, and will often use their finger to move food into proper position. (See "Pathogenesis and clinical manifestations of oropharyngeal dysphagia", section on 'Physiology of swallowing'.)
- A history of dry mouth or eyes may indicate inadequate salivary production. In such cases it is particularly important to obtain a detailed review of medications. Anticholinergics, antihistamines, and certain antihypertensive agents can reduce salivary flow. Sjögren's syndrome is also a consideration. A history of radiation therapy to the head and neck should also be noted. (See "Classification and diagnosis of Sjögren's syndrome".)
- Changes in speech may provide important clues, and often implicate neuromuscular dysfunction. Hoarseness or a weak cough may represent vocal cord paralysis. Slurred speech may indicate weakness or incoordination of muscles involved in articulation and swallowing. Dysarthria (abnormal articulation), and nasal speech or regurgitation of food into the nose may represent weakness of the soft palate or pharyngeal constrictors . The combination of hoarseness, dysphonia (difficulty or pain in speaking), and nasal speech accompanying dysphagia is associated with the muscular dystrophies.
- Food regurgitation, halitosis, a sensation of fullness in the neck, or a history of pneumonia accompanying dysphagia may be the result of a Zenker's diverticulum, which may be associated with a noncompliant or a hypertensive upper esophageal sphincter (image 1) . In addition, patients with a Zenker's diverticulum sometimes report coughing several minutes to hours after ingestion of a meal, which occurs during emptying of the diverticulum. Patients with intrinsic dysfunction of the upper esophageal sphincter (UES) may also present with frequent food impaction or aspiration . (See "Zenker's diverticulum".)
- Pain upon swallowing (odynophagia) can result from inflammation, infection, malignancy, or neoplasia.
- Dysphagia developing late in a meal may suggest myasthenia gravis. (See "Clinical manifestations of myasthenia gravis".)
- Oropharyngeal dysphagia is common after intubation, especially in patients with a history of prolonged intubation .