Dysphagia refers to difficulty swallowing and can be classified as oropharyngeal or esophageal. Oropharyngeal dysphagia is caused by abnormalities of the striated muscles in the mouth, pharynx, and upper esophageal sphincter. Esophageal dysphagia is caused by disorders of the smooth esophageal muscles. Common causes of oropharyngeal dysphagia include neurological diseases, local structural lesions, and disorders of the upper esophageal sphincter. Common causes of esophageal dysphagia include neuromuscular disorders like achalasia, mechanical lesions, and motility abnormalities. A thorough history and physical exam, along with diagnostic tests, are used to

1. Approach to dysphagiaApproach to dysphagia

2. Definition of DysphagiaDefinition of Dysphagia
The word dysphagia is derived from the Greek
phagia (to eat) and dys (with difficulty). It
specifically refers to the sensation of food being
hindered in its normal passage from the mouth
to the stomach.

3. CLASSIFICATIONCLASSIFICATION
Two distinct syndromesTwo distinct syndromes
Oropharyngeal dysphagiaOropharyngeal dysphagia Esophageal dysphagiaEsophageal dysphagia
Produced by abnormalitiesProduced by abnormalities
affecting the finely tunedaffecting the finely tuned
neuromuscular mechanismneuromuscular mechanism
of the striated muscle of theof the striated muscle of the
mouth, pharynx, and UESmouth, pharynx, and UES
Caused by the variety ofCaused by the variety of
disorders affecting thedisorders affecting the
smooth muscle esophagussmooth muscle esophagus

4. Oropharyngeal dysphagiaOropharyngeal dysphagia
 Inability to initiate the act of swallowing.
 It is a transfer problem caused by
 impaired ability to transfer food from mouth to upper esophagus
 impaired oral preparatory phase
 Clinical presentation:
 food sticking in the throat
 difficulty initiating a swallow
 nasal regurgitation
 coughing during swallowing
 They may also complain of
 dysarthria
 nasal speech because of associated muscle weaknesses
 Other Neurological clinical findings

5. Abnormalities Causing Oropharyngeal DysphagiaAbnormalities Causing Oropharyngeal Dysphagia
 Neuromuscular DiseasesNeuromuscular Diseases
 Central nervous system (CNS)Central nervous system (CNS)
 Cerebral vascular accident (e.g., brain stem or pseudobulbarCerebral vascular accident (e.g., brain stem or pseudobulbar
palsy)palsy)
 Parkinson diseaseParkinson disease
 Wilson diseaseWilson disease
 Multiple sclerosisMultiple sclerosis
 Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis
 Brain stem tumorsBrain stem tumors
 Tabes dorsalisTabes dorsalis
 Miscellaneous congenital and degenerative disorders of CNSMiscellaneous congenital and degenerative disorders of CNS

6. Abnormalities Causing Oropharyngeal DysphagiaAbnormalities Causing Oropharyngeal Dysphagia
 Neuromuscular DiseasesNeuromuscular Diseases
 Peripheral nervous systemPeripheral nervous system
 Bulbar poliomyelitisBulbar poliomyelitis
 Peripheral neuropathies (e.g., diphtheria, botulism, rabies,Peripheral neuropathies (e.g., diphtheria, botulism, rabies,
diabetes mellitus)diabetes mellitus)
 Motor end plateMotor end plate
 Myasthenia gravisMyasthenia gravis
 MuscleMuscle
 Muscular dystrophiesMuscular dystrophies
 Primary myositisPrimary myositis
 Metabolic myopathy (e.g., thyrotoxicosis, myxedema, steroidMetabolic myopathy (e.g., thyrotoxicosis, myxedema, steroid
myopathy)myopathy)
 AmyloidosisAmyloidosis
 SLESLE

7. Abnormalities Causing Oropharyngeal DysphagiaAbnormalities Causing Oropharyngeal Dysphagia
 Local Structural LesionsLocal Structural Lesions
 InflammatoryInflammatory
 PharyngitisPharyngitis
 AbscessAbscess
 TuberculosisTuberculosis
 SyphilisSyphilis
 NeoplasticNeoplastic
 Congenital websCongenital webs
 Plummer-Vinson syndromePlummer-Vinson syndrome
 Extrinsic compressionExtrinsic compression
 ThyromegalyThyromegaly
 cervical spine hyperostosiscervical spine hyperostosis
 LymphadenopathyLymphadenopathy
 Surgical resection of the oropharynxSurgical resection of the oropharynx

8. Abnormalities Causing Oropharyngeal DysphagiaAbnormalities Causing Oropharyngeal Dysphagia
 Disorders of the Upper Esophageal Sphincter (UES)Disorders of the Upper Esophageal Sphincter (UES)
 Hypertensive UES (i.e., spasm, possibly in globus, orHypertensive UES (i.e., spasm, possibly in globus, or
gastroesophageal refluxgastroesophageal reflux
 Hypotensive UES (e.g., esophagopharyngeal regurgitation orHypotensive UES (e.g., esophagopharyngeal regurgitation or
aspiration)aspiration)
 Abnormal UES relaxation or openingAbnormal UES relaxation or opening
 Incomplete relaxation (e.g., cricopharyngeal achalasia CNSIncomplete relaxation (e.g., cricopharyngeal achalasia CNS
lymphoma, oculopharyngeal muscular dystrophy)lymphoma, oculopharyngeal muscular dystrophy)
 Inadequate opening (e.g., cricopharyngeal bar, Zenker diverticulum)Inadequate opening (e.g., cricopharyngeal bar, Zenker diverticulum)
 Delayed relaxation (e.g., familial dysautonomia)Delayed relaxation (e.g., familial dysautonomia)

9. Etiology Of Esophageal Dysphagia
Neuromuscular (Motility) DisordersNeuromuscular (Motility) Disorders
 Most commonMost common
 AchalasiaAchalasia
 SclerodermaScleroderma
 Diffuse esophageal spasmDiffuse esophageal spasm
 Other associated motility abnormalitiesOther associated motility abnormalities
 Nutcracker esophagusNutcracker esophagus
 Hypertensive lower esophageal sphincterHypertensive lower esophageal sphincter
 Vigorous achalasiaVigorous achalasia
 Nonspecific esophageal dysmotilityNonspecific esophageal dysmotility
 Other secondary motility disordersOther secondary motility disorders
 Other collagen disordersOther collagen disorders
 Chagas diseaseChagas disease

10. Etiology Of Esophageal Dysphagia
Mechanical Lesions, IntrinsicMechanical Lesions, Intrinsic
 Most commonMost common
 Peptic stricturePeptic stricture
 Lower esophageal (Schatzki) ringLower esophageal (Schatzki) ring
 CarcinomaCarcinoma
 OtherOther
 Esophageal websEsophageal webs
 Esophageal diverticulaEsophageal diverticula
 Benign tumorsBenign tumors
 Foreign bodiesForeign bodies

11. Etiology Of Esophageal Dysphagia
Mechanical Lesions, ExtrinsicMechanical Lesions, Extrinsic
 Vascular compressionVascular compression
 Mediastinal abnormalitiesMediastinal abnormalities
 Cervical osteoarthritisCervical osteoarthritis

12. Esophageal Dysphagia

Three important questions are particularly crucial.
 What kind of food (i.e., liquid or solid) produces the symptom?
 Is the dysphagia intermittent or progressive?
 Is there associated heartburn?
 Physical examination is usually not revealing in patients
with esophageal dysphagia, with the exception of
scleroderma.

13. Diagnosis
 History
 Examination
 CBC
 CxR
 Barium studies
 Endoscopy
 Computed tomography scanning
 Endoscopic ultrasound
 Endoscopy
 Esophageal Manometry
 Esophageal pH studies