Oropharyngeal dysphagia: Clinical features, diagnosis, and management
- Anthony J Lembo, MD
Anthony J Lembo, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Nicholas J Talley, MD, PhD
Nicholas J Talley, MD, PhD
- Section Editor — Motility Disorders
- Professor of Medicine, University of Newcastle, Australia
- Adjunct Professor of Medicine and Epidemiology and Consultant, Mayo Clinic, Rochester, MN
- Adjunct Professor, University of North Carolina
- Daniel G Deschler, MD, FACS
Daniel G Deschler, MD, FACS
- Section Editor — Otorhinolaryngology
- Professor of Otology and Laryngology
- Harvard Medical School
Patients with oropharyngeal dysphagia have difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process.
This topic will review the evaluation and treatment of oropharyngeal dysphagia. Our recommendations are largely consistent with the American Gastroenterological Association (AGA) guidelines on the management of oropharyngeal dysphagia (algorithm 1) . An overview of dysphagia; the etiology and evaluation of patients with esophageal dysphagia; the etiology and pathogenesis of oropharyngeal dysphagia; and the etiology, assessment, and management of swallowing disorders in palliative care populations are discussed separately. (See "Overview of dysphagia in adults" and "Oropharyngeal dysphagia: Etiology and pathogenesis" and "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
●Dysphagia is defined as a subjective sensation of difficulty or abnormality of swallowing.
●Oropharyngeal or transfer dysphagia is characterized by difficulty initiating a swallow. Swallowing may be accompanied by nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx.
●Esophageal dysphagia is characterized by difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck. (See "Overview of dysphagia in adults", section on 'History' and "Overview of dysphagia in adults", section on 'Differential diagnosis of esophageal dysphagia'.)
- American Gastroenterological Association medical position statement on management of oropharyngeal dysphagia. Gastroenterology 1999; 116:452.
- Hendrix TR. Art and science of history taking in the patient with difficulty swallowing. Dysphagia 1993; 8:69.
- Rothstein RD. A systematic approach to the patient with dysphagia. Hosp Pract (1995) 1997; 32:169.
- Shapiro J. Oropharyngeal dysphagia: pathophysiology, clinical assessment and management. Rev Gastroenterol Mex 1994; 59:91.
- Duranceau A. Oropharyngeal dysphagia and disorders of the upper esopharyngeal sphincter. Ann Chir Gynaecol 1995; 84:225.
- Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology 1992; 103:1229.
- Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest 2010; 137:665.
- Kahrilas PJ. Current investigation of swallowing disorders. Baillieres Clin Gastroenterol 1994; 8:651.
- Poorjavad M, Derakhshandeh F, Etemadifar M, et al. Oropharyngeal dysphagia in multiple sclerosis. Mult Scler 2010; 16:362.
- Barloon TJ, Bergus GR, Lu CC. Diagnostic imaging in the evaluation of dysphagia. Am Fam Physician 1996; 53:535.
- Koch WM. Swallowing disorders. Diagnosis and therapy. Med Clin North Am 1993; 77:571.
- Castell JA, Dalton CB, Castell DO. Pharyngeal and upper esophageal sphincter manometry in humans. Am J Physiol 1990; 258:G173.
- Olsson R, Castell JA, Castell DO, Ekberg O. Solid-state computerized manometry improves diagnostic yield in pharyngeal dysphagia: simultaneous videoradiography and manometry in dysphagia patients with normal barium swallows. Abdom Imaging 1995; 20:230.
- Rubesin SE. Oral and pharyngeal dysphagia. Gastroenterol Clin North Am 1995; 24:331.
- Dodds WJ, Stewart ET, Logemann JA. Physiology and radiology of the normal oral and pharyngeal phases of swallowing. AJR Am J Roentgenol 1990; 154:953.
- Stoeckli SJ, Huisman TA, Seifert B, Martin-Harris BJ. Interrater reliability of videofluoroscopic swallow evaluation. Dysphagia 2003; 18:53.
- Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope 2007; 117:1723.
- Kelly AM, Leslie P, Beale T, et al. Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? Clin Otolaryngol 2006; 31:425.
- Castell JA, Castell DO. Upper esophageal sphincter and pharyngeal function and oropharyngeal (transfer) dysphagia. Gastroenterol Clin North Am 1996; 25:35.
- Pandolfino JE, Kahrilas PJ, American Gastroenterological Association. AGA technical review on the clinical use of esophageal manometry. Gastroenterology 2005; 128:209.
- Corso MJ, Pursnani KG, Mohiuddin MA, et al. Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux. Dig Dis Sci 1998; 43:1513.
- Gerhardt DC, Shuck TJ, Bordeaux RA, Winship DH. Human upper esophageal sphincter. Response to volume, osmotic, and acid stimuli. Gastroenterology 1978; 75:268.
- Thompson DG, Andreollo NA, McIntyre AS, Earlam RJ. Studies of the oesophageal clearance responses to intraluminal acid. Gut 1988; 29:881.
- Kilman WJ, Goyal RK. Disorders of pharyngeal and upper esophageal sphincter motor function. Arch Intern Med 1976; 136:592.
- Margulies SI, Brunt PW, Donner MW, Silbiger ML. Familial dysautonomia. A cineradiographic study of the swallowing mechanism. Radiology 1968; 90:107.
- RILEY CM. Familial dysautonomia. Adv Pediatr 1957; 9:157.
- Bender MD. Esophageal manometry in oculopharyngeal dystrophy. Am J Gastroenterol 1976; 65:215.
- Bonanno PC. Swallowing dysfunction after tracheostomy. Ann Surg 1971; 174:29.
- Duranceau A, Jamieson G, Hurwitz AL, et al. Alteration in esophageal motility after laryngectomy. Am J Surg 1976; 131:30.
- Dantas RO, Cook IJ, Dodds WJ, et al. Biomechanics of cricopharyngeal bars. Gastroenterology 1990; 99:1269.
- Ghosh SK, Pandolfino JE, Zhang Q, et al. Deglutitive upper esophageal sphincter relaxation: a study of 75 volunteer subjects using solid-state high-resolution manometry. Am J Physiol Gastrointest Liver Physiol 2006; 291:G525.
- Omari TI, Dejaeger E, Van Beckevoort D, et al. A novel method for the nonradiological assessment of ineffective swallowing. Am J Gastroenterol 2011; 106:1796.
- Miller RM, Langmore SE. Treatment efficacy for adults with oropharyngeal dysphagia. Arch Phys Med Rehabil 1994; 75:1256.
- Langmore SE. Efficacy of behavioral treatment for oropharyngeal dysphagia. Dysphagia 1995; 10:259.
- Logemann JA, Kahrilas PJ. Relearning to swallow after stroke--application of maneuvers and indirect biofeedback: a case study. Neurology 1990; 40:1136.
- Bryant M. Biofeedback in the treatment of a selected dysphagic patient. Dysphagia 1991; 6:140.
- Lazarus C, Logemann JA, Gibbons P. Effects of maneuvers on swallowing function in a dysphagic oral cancer patient. Head Neck 1993; 15:419.
- Logemann JA, Kahrilas PJ, Kobara M, Vakil NB. The benefit of head rotation on pharyngoesophageal dysphagia. Arch Phys Med Rehabil 1989; 70:767.
- Virani A, Kunduk M, Fink DS, McWhorter AJ. Effects of 2 different swallowing exercise regimens during organ-preservation therapies for head and neck cancers on swallowing function. Head Neck 2015; 37:162.
- Rosenvinge SK, Starke ID. Improving care for patients with dysphagia. Age Ageing 2005; 34:587.
- Hammond CAS, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:154S.
- Bates B, Choi JY, Duncan PW, et al. Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. Stroke 2005; 36:2049.
- Clavé P, de Kraa M, Arreola V, et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Aliment Pharmacol Ther 2006; 24:1385.
- Rofes L, Arreola V, Mukherjee R, et al. The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia. Aliment Pharmacol Ther 2014; 39:1169.
- Buchholz DW. Cricopharyngeal myotomy may be effective treatment for selected patients with neurogenic oropharyngeal dysphagia. Dysphagia 1995; 10:255.
- Poirier NC, Bonavina L, Taillefer R, et al. Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia. J Thorac Cardiovasc Surg 1997; 113:233.
- Campbell BH, Tuominen TC, Toohill RJ. The risk and complications of aspiration following cricopharyngeal myotomy. Am J Med 1997; 103:61S.
- Cañete-Gómez J, Ramírez-Plaza CP, López Rueda B, et al. [Diverticulectomy and cricopharyngeal myotomy for the treatment of Zenker's diverticulum. a presentation of 33 cases]. Cir Esp 2012; 90:233.
- Brigand C, Ferraro P, Martin J, Duranceau A. Risk factors in patients undergoing cricopharyngeal myotomy. Br J Surg 2007; 94:978.
- Blitzer A, Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia. Otolaryngol Head Neck Surg 1997; 116:328.
- Schneider I, Thumfart WF, Pototschnig C, Eckel HE. Treatment of dysfunction of the cricopharyngeal muscle with botulinum A toxin: introduction of a new, noninvasive method. Ann Otol Rhinol Laryngol 1994; 103:31.
- Zaninotto G, Marchese Ragona R, Briani C, et al. The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia. J Gastrointest Surg 2004; 8:997.
- Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg 2007; 133:564.
- Zepeda-Gómez S, Montaño Loza A, Valdovinos F, et al. Endoscopic balloon catheter dilation for treatment of primary cricopharyngeal dysfunction. Dig Dis Sci 2004; 49:1612.
- CLINICAL FEATURES
- DETERMINING THE ETIOLOGY
- Initial evaluation
- - History
- - Physical examination
- - Laboratory testing and imaging
- Subsequent evaluation
- - Videofluoroscopic modified barium swallow
- - Nasopharyngeal laryngoscopy
- - Fiberoptic endoscopic evaluation of swallowing
- - Manometry
- Neuromuscular disorders
- - Swallowing rehabilitation and nutrition
- - Cricopharyngeal myotomy
- - Botulinum toxin injection
- - Neuromuscular electrical stimulation
- Structural disorders
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS