Specialist ENT CAUSES OF DYSPHAGIA

CAUSES OF DYSPHAGIA

Definition:

Dysphagia means difficulty in swallowing. The term odynophagia is used for painful swallowing.

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I. Local causes in the alimentary canal:

Acute and painful:

a) Acute Inflammation of mouth.

b) Carcinoma posterior 2/3rd tongue.

c) Acute tonsillitis, quinsy, acute laryngitis.

d) Acute oesophagitis, reflux oesophagitis, peptic ulcer of oesophagus.

e) Corrosive injuries by ingestion of corrosive fluids.

f) Foreign body impaction.

Chronic and painless: a) Laryngeal tuberculosis, laryngeal carcinoma.
b) Pharyngeal pouch, pharyngeal carcinoma. c) Oesophageal causes:

    i. Localized muscular spasm: Cardiospasm, Plummer Vinson Syndrome.

    ii. Congenital strictures.

    iii. Simple strictures.

      ➣ Corrosion by swallowed poisons.

      ➣ Secondary to reflux Oesophagitis.

      ➣ Schatzki’s ring.

      ➣ Tubular strictures.

      ➣ Carcinoma oesophagus.

II. Local causes outside alimentary canal:

Acute and painful:

a) Acute submandibular sialadenitis.

b) Acute cervical lymphadenitis of neck.

c) Acute thyroiditis.

d) Acute suppurative pericarditis.

e) Acute mediastinitis.

Chronic painless:

a) Carcinoma thyroid, thyroid goiter

b) Malignant cervical lymphadenitis.

c) Aortic aneurysms.

d) Mediastinal tumors.

III. Distant causes of dysphagia:

a) Paralysis of palate, pharynx, vagus nerve, example diphtheria, lead palsy.

b) Hysteric spasm.

c) Hydrophobia.

d) Tetanus.

e) Myasthenia gravis.

f) Polio encephalitis.

Investigation: 1. History with suggestive pathology

    a) Sudden onset: Foreign body or impaction of food on a preexisting stricture or malignancy, neurological disorders.

    b) Progressive: Malignancy.

    c) Intermittent: Spasms or spasmodic episodes over an organic lesion.

    d) Dysphagia more to liquids seen in paralytic lesions.

    e) Dysphagia more to solids and progressing even to liquids seen in malignancy or strictures.

    f) Ulcerative lesions cause intolerance to acid food or fruit juices.

    g) Regurgitation and heart burn (hiatus hernia).

    h) Regurgitation of undigested food while lying down, with cough at night (pharyngeal pouch).

    i) Aspiration into lungs (laryngeal paralysis).

    j) Aspiration into the nose (palatal paralysis).

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2) Clinical examination

Examination of oral cavity, oropharynx, larynx and hypopharynx done to exclude       pre-oesophageal causes of dysphagia. Examination of the neck, chest and nervous system done.

3. Blood examination to exclude Plummer–Vinson syndrome and to know the nutritional status of the patient.

4. Radiography 

  1. X-ray chest to exclude cardiovascular, pulmonary and mediastinal diseases.
  2. Lateral view neck to exclude cervical osteophytes and any soft tissue lesions of postcricoid or retropharyngeal space. 
  3. Barium swallow to diagnose malignancy, cardiac achalasia, strictures, diverticula, hiatus hernia or oesophageal spasms.

5. Manometric and pH studies  are done to help in motility disorders, gastro-oesophageal reflux and to differentiate whether oesophageal spasms are spontaneous or acid induced.

6. Oesophagoscopy for direct examination of oesophageal mucosa and if needed biopsy can be taken from the suspected oesophagus.

7. Other investigations– Bronchoscopy (for bronchial carcinoma), cardiac catheterization (for vascular anomalies), thyroid scan (for malignant thyroid) may be required, depending on the case.

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