Oropharyngeal and esophageal motility disorders have significant impact on patients' quality of life. Mechanical and functional problems may interact to cause symptoms; thus, diagnosis of these disorders can be challenging.
Dysphagia (difficulty swallowing) must be distinguished from other symptoms such as odynophagia (pain on swallowing, suggestive of a defect in mucosal integrity, eg, from irradiation, inflammation, or infection) and aphagia (inability to swallow, generally suggestive of mechanical obstruction in patients presenting acutely). Symptoms that do not necessarily correlate with the immediate process of swallowing, such as rumination and globus sensation, should also be discerned.
Dysphagia can be differentiated into two categories: (1) oropharyngeal (also called transfer dysphagia), arising from disorders affecting the oropharynx, larynx, and upper esophageal sphincter (UES); and (2) esophageal, arising from the esophagus, lower esophageal sphincter (LES), or gastroesophageal junction. The causes of dysphagia are many, and specific entities are considered here.
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- History of poor oral bolus preparation and control, difficulty in initiating a swallow, nasal and oral regurgitation, aspiration and coughing with swallowing, food sticking at the level of the throat.
- Evidence of a generalized neuromuscular disorder.
- Documentation by videofluoroscopic swallowing study (VFSS).
Many neuromuscular disorders can cause dysphagia (Table 13–1). Among these are various disorders causing cortical lesions; supranuclear, nuclear, and cranial nerve lesions; defects of neurotransmission at the motor end plates; and muscular diseases.
Table 13–1. Neuromuscular Disorders Causing Oropharyngeal Dysphagia. ||Download (.pdf)
Table 13–1. Neuromuscular Disorders Causing Oropharyngeal Dysphagia.
Diseases of cerebral cortex and brainstem
With altered consciousness or dementia
- Dementias, including Alzheimer disease
- Altered consciousness, metabolic encephalopathy, encephalitis, meningitis, cerebrovascular accident, brain injury
With normal cognitive functions
- Brain injury
- Cerebral palsy
- Rabies, tetanus, neurosyphilis
- Cerebrovascular disease
- Parkinson disease and other extrapyramidal lesions
- Multiple sclerosis (bulbar and pseudobulbar palsy)
- Amyotrophic lateral sclerosis (motor neuron disease)
- Poliomyelitis and post-poliomyelitis syndrome
Diseases of cranial nerves (V, VII, IX, X, XII)
Basilar meningitis (chronic inflammatory, neoplastic)
Neuropathy (Guillain-Barré syndrome, Bell palsy, afamilial dysautonomia, sarcoid, diabetic, and other causes)
Aminoglycosides and other drugs
Myositis (polymyositis, dermatomyositis, sarcoidosis)
Metabolic myopathy (mitochondrial myopathy, thyroid myopathy)
Primary myopathies (myotonic dystrophy, oculopharyngeal myopathy)
Acute and chronic radiation injury