Dysphagia and Odynophagia

GENERAL PRINCIPLES

• Oropharyngeal dysphagia consists of difficulty in transferring food from the mouth to the esophagus, often associated with nasopharyngeal regurgitation and aspiration.

• Esophageal dysphagia is the sensation of impairment in passage of food down the tubular esophagus. Etiologies include obstructive processes (e.g., webs, rings, esophagitis, neoplasia) or esophageal motor disorders.²⁹

• Odynophagia is pain on swallowing food and fluids and may indicate the presence of esophagitis, particularly infectious esophagitis or pill esophagitis.

DIAGNOSIS

Oropharyngeal Dysphagia

• A detailed neurologic examination is the first diagnostic step. Barium videofluoroscopy (modified barium swallow) evaluates the oropharyngeal swallow mechanism and may identify laryngeal penetration.

• Ear, nose, and throat examination; flexible nasal endoscopy; and imaging studies may identify structural etiologies.

• Laboratory tests for polymyositis, myasthenia gravis, and other neuromuscular disorders are performed when neurologic or structural etiologies are not evident.

Esophageal Dysphagia

• EGD is the initial test of choice as it identifies mucosal and structural abnormalities, allows tissue sampling (to evaluate for esophageal eosinophilia or for conclusive diagnosis of suspected neoplasia),

and offers the option of dilation, which should be performed for most esophageal strictures.^30,31

• Esophageal manometry, preferably high-re solution manometry (HRM), should be performed when other studies are normal or suggest an esophageal motility disorder. The image-based paradigm of Clouse plots on HRM has simplified testing procedures, allowing for easier analysis, and improved diagnostic utility over conventional manometry.³² Provocative maneuvers during HRM can prevent under- and overdiagnosis of motility disorders.

• Endoluminal functional lumen imaging probe (FLIP) evaluates compliance and distensibility of the esophagus and esophagogastric junction, with the potential for higher sensitivity in the detection of esophageal outflow obstruction compared with manometry. FLIP utilizes impedance planimetry during volume-controlled distention of a compliant balloon to measure cross-sectional area, from which a distensibility index is calculated.³³

• Barium swallow defines anatomy and identifies subtle rings and strictures, which may only be seen with a barium pill or a solid barium bolus.³⁴

• Acute esophageal obstruction is best investigated with endoscopy. Barium studies should not be performed when esophageal obstruction is suspected because barium can obscure visualization during endoscopy and may take several days to clear. If a contrast study is needed, water-soluble contrast should be used.

TREATMENT

• Modification of diet and swallowing maneuvers directed by a speech pathologist improve especially oropharyngeal dysphagia. Patients with dysphagia are advised to chew their food well and eat foods of soft consistencies.

• Enteral feeding through a gastrostomy tube is indicated when frank tracheal aspiration is identified on attempted swallowing.

• Endoscopic retrieval of an obstructing food bolus relieves acute dysphagia. This is typically followed by further evaluation, including esophageal biopsies, and subsequent endoscopy for dilation.

• Nutrition needs to be addressed in patients with prolonged dysphagia causing weight loss.

Medications

• Mucosal inflammation from reflux disease can be treated with acid suppression.

• Odynophagia generally responds to specific therapy when the cause is identified (e.g., PPIs for reflux disease, antimicrobial agents for infectious esophagitis). Viscous lidocaine swish-and-swallow solutions may afford symptomatic relief.

• Anticholinergic medication (e.g., transdermal scopolamine) helps drooling of saliva.

• Glucagon (2-4 mg IV bolus) or sublingual nitroglycerin can be attempted in acute food impaction, but meat tenderizer should not be administered.

Nonpharmacologic Therapies

• Esophageal dilation is performed for strictures, rings, and webs.³¹ Empiric bougie dilation may provide symptomatic benefit even when a defined narrowing is not identified in some settings, especially when dysphagia is localized to the high neck, and eosinophilic esophagitis has been excluded.

• Pneumatic dilation of the lower esophageal sphincter (LES) and peroral endoscopic myotomy (POEM) are options for achalasia management (see Esophageal Motor Disorders section). Botulinum toxin injection into the LES provides temporary symptom relief in achalasia and esophageal outflow

obstruction from motor etiologies.³¹

• Esophageal stent placement can alleviate dysphagia from inoperable neoplasia.