Dysphagia means difficulty moving food or liquid from the mouth to the hypopharynx (the lowest part of the pharynx, where the swallow passes into the esophagus) or through the esophagus. It is a symptom rather than a diagnosis, and the first useful question is where in the swallow the trouble lies.
Several related terms are used with dysphagia, and each describes a different part of the picture:
- Aphagia — complete inability to swallow, due to esophageal obstruction.
- Odynophagia — painful swallowing, caused by mucosal ulceration or inflammation of the mouth, pharynx or esophagus.
- Globus pharyngeus — a sensation of a foreign body in the neck, sometimes relieved by swallowing.
- Transfer dysphagia — related to nasal regurgitation or pulmonary aspiration, and mostly due to oropharyngeal dysphagia.
- Phagophobia — fear of swallowing, either due to psychotic conditions or anticipatory anxiety about the dysphagia.
A normal swallow needs a bolus of the right size and consistency, an open lumen, effective peristalsis and timely relaxation of the sphincters, so dysphagia appears when one of these fails.
Where to start
The key distinction is where the swallow fails, and whether the cause is structural (a bolus that cannot pass an obstructed or narrowed lumen) or propulsive (a lumen that is open but is not driven or relaxed properly).
- Swallowing physiology and dysphagia pathophysiology — how a normal swallow works, and how structural and propulsive abnormalities produce dysphagia.
- Oropharyngeal and esophageal dysphagia — how dysphagia at the two levels differs in presentation and what causes each.
- Approach to the patient with dysphagia — the history, and the alarm features, that narrow the cause.
- Investigating dysphagia — the tests used at each level, and when to choose them.
- Management of dysphagia — how the cause is treated, and how aspiration and malnutrition are prevented.