Dysphagia

Author Credentials 

Karuna Dewan, MD
Assistant Professor, Department of Otolaryngology – Head & Neck Surgery
Stanford University School of medicine
801 Welch Road
Stanford, CA

Dinesh K. Chhetri, MD
Professor, Department of Head & Neck Surgery
David Geffen School of Medicine at UCLA
200 Medical Plaza, Suite 550
Los Angeles, CA

Module Summary

Dysphagia is an increasingly common problem. The etiologies are varied and can be identified based upon a comprehensive history and physical examination. Treatment options are both medical and surgical.

Module Learning Objectives 
  1. Describe the presenting symptoms and signs and diagnostic tools used in the workup of dysphagia.
  2. Review the theories of the pathogenesis of dysphagia.
  3. Explain the efficacy of current surgical procedures used to treat dysphagia.
  4. Recognize that dysphagia is not a single disease but a symptom of an underlying medical problem.

Embryology

Learning Objectives 

Understand the development of the upper alimentary tract.

  1. The surface ectoderm invaginates to form the stomodeum – the lining of the future oral cavity. The endoderm in this area will form the pharynx, larynx, trachea and esophagus.
  2. Post-otic somites become the tongue muscles innervated by nerve XII.
References 
  1. Netter’s Atlas of Human Embryology. Cochard LR. Icon: New Jersey. 2002.

Anatomy

Learning Objectives 

Understand the three functions of the larynx and how this influences the development of dysphagia.

References 
  1. Weaker, F. Structures of the Head and Neck. Davis:Philadelphia, 2014.

Pathogenesis

Learning Objectives 
  1. Understand the general principles involved in swallowing:
    1. Central control – the part of swallowing that is controlled by the brain
    2. Peripheral control – the nervous feedback that occurs at the end-organ level
    3. The “pump and the pipe” concept – The base of tongue and oropharynx acts as a piston/pump, effectively pushing the bolus toward the esophageal inlet. The pipe is the pharyngeal conduit and the esophagus.
    4. Coordination – swallowing is a complex patterned task – it requires coordination from the central and peripheral nervous systems. In addition it requires coordination of multiple muscles. Loss of coordination between any of the multiple steps, or any dysfunction in these structures, results in dysphagia.
  2. Understand the dysphagia may be present in any phase of swallowing:
    1. Oral phase
    2. Pharyngeal phase
    3. Esophageal phase
  3. Understand the many types and causes of dysphagia:
    1. Neurogenic dysphagia
    2. Dysphagia due to head and neck tumors
    3. Chemoradiation induced dysphagia
    4. Dysphagia due to epiglottic dysfunction
    5. Dysphagia due to cervical osteophytes
    6. Dysphagia present in glottic insufficiency
    7. Cricopharyngeal muscle achalasia
    8. Zenker’s diverticulum and esophageal pouches
    9. Eosinophilic Esophagitis
References 
  1. Bhattacharyya N. The prevalence of dysphagia among adults in the United States. Otolaryngol Head Neck Surg. 2014;151(5):765-9
  2. Spieker, M. Evaluating Dysphagia. Am Fam Physician. 2000 Jun 15;61(12):3639-3648
  3. Hirano I, Kahrilas PJ (2012). Dysphagia. In DL Longo et al., eds., Harrison's Principles of Internal Medicine, 18th ed., vol. 1, pp. 297-300. New York: McGraw-Hill.

Basic Science

Learning Objectives 
  1. Know that deglutition involves the oral cavity, pharynx, larynx and esophagus.
  2. The pharyngeal structures involved in deglutition include the three pharyngeal constrictors – superior, middle and inferior. The cricopharyngeus muscle is the most inferior structure of the pharynx and serves as a sphincter at the inlet to the esophagus.
  3. Understand that the esophagus is a muscular tube consisting of both smooth and striated muscle. It has a sphincter at each end.
  4. Understand that swallowing has phases: oral, pharyngeal, and esophageal.
References 
  1. Evaluation and Treatment of Swallowing Disorders. Logemann, J. Pro-ed, Austin, 1983.

Incidence

Learning Objectives 
  1. Understand that dysphagia is underdiagnosed in many patients and estimation of the true incidence of dysphagia is difficult.
  2. Understand that most common cause of dysphagia is neurogenic:
    1. Stroke: 1.7% of all stroke patients become G-tube dependent in the long term.
    2. Neuro-degenerative disorders: the incidence of dysphagia in patients with neurodegenerative disease is estimated to be 40%.
  3. Recognize the high propensity for dysphagia in head and neck cancer patients.
  4. Recognize that up to 40-60% of the institutionalized elderly have identifiable signs and symptoms of oropharyngeal dysphagia.
References 
  1. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 17, 139-146.
  2. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.
  3. Dogget, D.L., Tappe, K.A., Mitchell, M.D., Chapell, R., Coates, V., Turkelson, C.M. (2001). Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence based comprehensive analysis of the literature. Dysphagia 16, 279-295
  4. Becker, R., Nieczaj, R., Egge, K., Moll, A., Meinhardt, M., Schulz, R-J. (2010). Functional dysphagia therapy and PEG treatment in a clinical geriatric setting. Dysphagia, DOI 10.1007/s00455-009-9270-8.
  5. Nguyen, N.P., Frank, C., Moltz, C.C., Karlsson, U., Nguyen, P.D., Ward, H.W., Vos, P., Smith, H.J., Huang, S., Nguyen, L.M., Lemanski, C., Ludin, A., Sallah, S. (2009). Analysis of factors influencing dysphagia severity following treatment of head and neck cancer. Anticancer Research 29, 3299-3304.

Patient Evaluation

Learning Objectives 
  1. Know to ascertain during the history the following:
    1. Onset, duration and severity of swallowing problem.
    2. Dysphagia to liquids, solids or both.
    3. Relevant past medical history such as history of neck surgery, head and neck cancer, neurological diagnosis, etc.
  2. Know the objectives in dysphagia evaluation
    1. Recognize that dysphagia is present (some patients are not aware of their dysphagia (e.g. silent aspiration).
    2. Identify the anatomic region involved (oral, pharyngeal, esophageal).
    3. Acquire clues regarding the etiology of the condition.
  3. Recognize the signs and symptoms of dysphagia
    1. Oral/pharyngeal dysphagia: coughing/choking with swallowing, difficulty initiating swallow, food sticking in the throat, drooling, unexplained weight loss, change in dietary habits, recurrent pneumonia, change in voice or speech, nasal regurgitation.
    2. Esophageal dysphagia: sensation of food sticking in the chest, oral/pharyngeal regurgitation, food sticking in the throat, drooling, unexplained weight loss, change in dietary habits, recurrent pneumonia.
    3. Elicit symptoms related to esophageal reflux including heartburn, belching, sour regurgitation and chronic halitosis
    4. Review patient medications as some psychotropic medications can exacerbate dysphagia.
    5. Presence of dysphonia and dysphagia.
  4. Assess the role of following in dysphagia
    1. Neurologic, respiratory and connective tissue disorders.
    2. Oral health, dentition, trismus, mucosal integrity
    3. Soft palate position and function
    4. Hyolaryngeal elevation
    5. Neck Fibrosis/Cervical range of motion
  5. Understand the role of each of these tests in dysphagia evaluation
    1. FEES
    2. Barium esophagram
    3. HRM
    4. Esophagoscopy
References 
  1. Spieker, M. Evaluating Dysphagia. Am Fam Physician. 2000 Jun 15;61(12):3639-3648
  2. Atlas of Transnasal Esophagoscopy Postma GN, Belafsky PC, Aviv JE. Lippincott: Philadelphia 2007.
  3. Schlottman F, Patti M. Primary Esophageal Motility Disorders: Beyond Achalasia. Int. J. Mol. Sci, 18(7), 1399.
  4. Langmore S. History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years. Dysphagia. 2017, (32)27-38.
  5. Aviv JE, Murry T, Zschommler A et al. Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1,340 consecutive examinations. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):174-6

Measurement of Functional Status

Learning Objectives 

Know questionnaires that are available to assess functional status in dysphagia evaluation:

  1. The Dysphagia Handicap Index
  2. The Eating Assessment Tool (EAT-10)
  3. The Sydney swallowing questionnaire
  4. The swallowing outcome after Laryngectomy
  5. The Mayo dysphagia questionnaire-30
  6. The MD Anderson Dysphagia Inventory
References 
  1. Speyer R, Kertscher B, Cordier R. Functional Health Status in Oropharyngeal Dysphagia. Jrnl Gastro Hep Research. 2014(3)5.
  2. Silbergleit AK, Schultz L, Jacobson BH et al. The Dysphagia Handicap Index: development and validation. Dysphagia. 2012 Mar;27(1):46-52.
  3. Belafsky PC, Mouadeb DA, Rees CJ. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008 Dec;117(12):919-24.
  4. Dwivedi RC, St Rose S, Roe JW et al. Validation of the Sydney Swallow Questionnaire in a cohort of head and neck cancer patients. Oral Oncol. 2010 Apr;46(4):e10-4
  5. Govender R, Lee MT, Davies TC et al. Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire). Clin Otolaryngol. 2012 Dec;37(6):452-9.
  6. McElhiney J, Lohse MR, Arora AS et al. The Mayo Dysphagia Questionnaire-30: documentation of reliability and validity of a tool for interventional trials in adults with esophageal disease. Dysphagia. 2010 Sep;25(3):221-30.
  7. Chen AT, Frankowski R, Bishop-Leone J et al. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M.D. Anderson dysphagia inventory. Arch Otolaryngol Head Neck Surg. 2001 Jul;127(7):870-6.

Imaging

Learning Objectives 

Understand the role for radiographic imaging techniques of swallowing and their indications, advantages, and disadvantages.

  1. Modified barium study (MBS)
  2. Barium esophagram
References 
  1. Hiatt G. The roles of esophagoscopy vs. radiography in diagnosing benign peptic esophageal strictures. Gastrointestinal Endoscopy.(77)23;4, 194-195.
  2. Finkelstein Y. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope. 2002 Feb;112(2):409-12.
  3. Lee JW, Randal DR, Evangelista LM, et al. Subjective Assessment of Videofluoroscopic Swallow studies. Otolaryngol Head Neck Surg. 2017 May; 156(5):901-905.

Medical Therapies

Learning Objectives 
  1. Understand the role for Botox in dysphagia management.
  2. Understand the role for “VitalStim” in dysphagia management.
  3. Understand the role for dietary changes in dysphagia management.
  4. Understand the role for inhaled steroid in dysphagia management.
References 
  1. Kocdor P, Siegel ER, Tulunay-Ugur OE. Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilation, botulinum toxin injection and myotomy. Laryngoscope. 2016 Jan;126(1):135-41
  2. Moerman MB. Cricopharyngeal Botox injection: indications and technique. Curr Opin Otolaryngology Head Neck Surg. 2006 Dec;14(6):431-6.
  3. Dellon ES, et al. ACG Clinical guideline: evidence-based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Amer J Gastro. 108(5):679-692.
  4. Shaw GY, Sechtem PR, Searl J et al. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. 2007 Jan;116(1):36-44.
  5. Kiger M, Brown CS, Watkins L. Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia. 2006 Oct;21(4):243-53.

Surgical Therapies

Learning Objectives 

Understand the role of the following procedures in Dysphagia management:

  1. Cricopharyngeal myotomy
  2. Zenker’s Diverticulectomy
  3. Esophageal dilation
  4. Epiglottic surgery
  5. Cervical osteophyte resection
  6. Hypopharygoplasty/pharyngoplasty (pyriform sinus imbrication)
  7. Hyolaryngeal advancement
  8. Laryngotracheal separation
  9. Laryngectomy
  10. Glottic closure
  11. Epiglottic closure
References 
  1. Bergeron JL, Chhetri DK. Indications and outcomes of endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope. 2014 Apr;124(4):950-4.
  2. Peng KA, Feinstein AJ, Salinas JB, Chhetri DK. Utility of the transnasal esophagoscope in the management of chemoradiation-induced esophageal stenosis. Ann Otol Rhinol Laryngol. 2015 Mar;124(3):221-6.
  3. Cox JG, Winter RK, Maslin SC. Balloon or bougie for dilation of benign oesophageal stricture? Dig Dis Sci. 1994 Apr;39(4):776-81.
  4. Jamal N, Erman A, Chhetri DK. Transoral partial epiglottidectomy to treat dysphagia in post-treatment head and neck cancer patients: a preliminary report. Laryngoscope. 2014 Mar;124(3):665-71.
  5. Jamal N, Erman A, Chhetri DK. Partial Epiglottoplasty for pharyngeal dysphagia due to cervical spine pathology. Otolaryngol Head Neck Surg. 2015 Oct;153(4):586-92.
  6. Di Vito J. Cervical Osteophytic dysphagia: single and combined mechanisms. Dysphagia. 1998 Winter;13(1):58-61.
  7. Giraldez-Rodriguez L, Johns M. Glottal Insufficiency with Aspiration Risk in Dysphagia. Otolaryngol Clin North Am. 2013 Dec;46(6):1113-21.
  8. Venkatesan NN, Johnson CM, Siddiqui MT et al. Comparison of swallowing outcomes of laryngotracheal separation versus total laryngectomy in a validated ovine model of profound oropharyngeal dysphagia. J Laryngol Otol. 2017 Apr;131(4):350-356.
  9. Eisele DW, Yarington CT, Lindeman RC et al. The tracheoesophageal diversion and laryngotracheal separation procedures for treatment of intractable aspiration. Am J Surg. 1989 Feb; 157(2):230-6.
  10. Sato K, Nakashima T. Surgical closure of the larynx for intractable aspiration, using double hinged flaps of the vocal folds and false vocal folds. J Laryngol Otol. 2006 Sep;120(9):759-63.
  11. Sato K, Nakashima T. Surgical closure of the larynx for intractable aspiration: surgical technique using closure of the posterior glottis. Laryngoscope. 2003 Jan;113(1):177-9.

Rehabilitation

Learning Objectives 
  1. Understand the role of the speech language pathologist in management of Dysphagia.
    1. Know who is a candidate for Swallowing therapy.
    2. Know compensatory swallow maneuvers that can be used in effective swallowing (e.g. head turn, chin tuck, supraglottic and super supraglottic swallow, etc.)
    3. Know swallow therapy techniques and when they are applicable (e.g.effortful swallow, Mendelsohn maneuver, etc.)
    4. Know the role for indirect swallow exercises (e.g. tongue strengthening, Shaker head raise, expiratory muscle strength training, etc.).
  2. Understand the etiology and treatment for trismus.
  3. Understand the role for swallow preservation exercises during head and neck cancer treatment.
References 
  1. Altman KW. Dysphagia: Diagnosis and Management. Oto Clinics. 2013 Dec;46(6):206-219.
  2. Duarte VM, Chhetri DK, Liu YF, Erman AA< Wang MB. Swallow Preservation exercises during chemoradiation therapy maintains swallow function. Otolaryngol head Neck Surg. 2013 Dec;149(6):878-84.
  3. Gaziano JE. Evaluation and management of oropharyngeal dysphagia in head and neck cancer. Cancer Control. 2002;9(5):400-409.
  4. Kraaijenga S, van der Molen L, van Tinteren H, et al. Treatment of myogenic temporomandibular disorder: A prospective randomized clinical trial, comparing a mechanical stretching device (TheraBite®) with standard physical therapy exercise. Cranio. 2014;32(3):208-216.

Case Studies

  1. A 49 year old male presents with a five year history of gradually worsening dysphagia to solids. He has a history of tonsil cancer and completed radiation 5 years prior to presentation. He often feels like food gets stuck in his throat. He constantly has to clear his throat and requires copious fluid with each meal to help food to go down. The patient is maintaining his weight. He denies history of aspiration pneumonia. What are the pertinent head and neck structures to examine? What are the etiologies of dysphagia in this setting? Which tests of swallow function are applicable? What surgical procedures might be needed? What is the role for swallow therapy?
  2. A 34 year old male with a history of traumatic brain injury 15 years prior and alcoholism presents with a complaint of dysphagia. He indicates that when he eats he feels like his throat is too narrow for the food to pass through. This sensation has caused him to severely restrict what he eats. The patient denies recent weight loss. Denies history of aspiration pneumonia. What role might TBI and/or alcoholism play in the current presentation of dysphagia? What tests are needed to assess swallow function?

Complications

Learning Objectives 
  1. Know the potential complications of untreated dysphagia
    1. Malnutrition
    2. Aspiration pneumonia
    3. Dehydration
  2. Know the potential complications that may follow treatment of dysphagia.
    1. Refeeding syndrome
References 
  1. Altman KW. Dysphagia: Diagnosis and Management. Oto Clinics. 2013 Dec;46(6):188-198.
Resources 

Learner must Sign In to access AAO-HNSF education activities.

  1. Annual Meeting Webcasts (AMW):
  2. eCourse:
  3. ENT for the PA-C (PAc)