A 52-year-old gentleman comes to your office with a history of intermittent difficulty swallowing solid food. His symptoms have been present for the past 5 years. He points to his supraclavicular notch when describing where the food feels stuck, although he is able to chew his food and transfer it into his posterior pharynx without difficulty. He does not choke or cough while eating. Drinking water will usually relieve his symptoms, although on several occasions he has self-induced vomiting. His symptoms are slightly worse now than they were several years ago, which prompted today's visit.
- Would you classify his dysphagia as esophageal or oropharyngeal?
- What symptoms help determine whether his dysphagia is due to a mechanical or motor (ie, motility) abnormality?
- How can you use the patient's history to distinguish between a benign and malignant cause of his dysphagia?
The word dysphagia derives from the Greek words dys (with difficulty) and phagein (to eat) and is defined as difficulty in swallowing. It is the sensation of hesitation or delay in passage of food during swallowing. Therefore, dysphagia differs from odynophagia, which refers to pain with swallowing. It also differs from globus, which is the sensation of a lump or tightness in the throat unrelated to swallowing. The complaint of dysphagia, especially when it is a new symptom, should always be taken seriously because it is the most common presenting symptom of neoplasm of the esophagus.
Dysphagia can be classified as either oropharyngeal or esophageal.1 These are distinct processes that require different evaluation and management. Oropharyngeal (or transfer) dysphagia occurs from disorders that affect the oropharyngeal area, typically from neurologic or myogenic abnormalities as well as oropharyngeal tumors. Esophageal dysphagia occurs from disorders of the esophagus and is most commonly due to mechanical obstruction or altered motility of the esophagus. A detailed history can distinguish between the 2 types of dysphagia and with further evaluation can establish the diagnosis in 80% to 85% of cases.2
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|Esophageal dysphagia||Difficulty in passage of a bolus from the upper esophagus to the stomach.|
|Globus||Sensation of lump or tightness in the throat unrelated to swallowing.|
|Mechanical disorder||Obstruction of the esophageal lumen.|
|Motor disorder of the esophagus||Dyscoordination of the esophageal contractions.|
|Odynophagia||Pain with swallowing.|
|Oropharyngeal dysphagia||Difficulty initiating the swallowing process (ie, passage of a bolus from the mouth to the proximal esophagus).|
The exact prevalence of dysphagia is unknown. Current studies estimate the prevalence of dysphagia to be between 16% and 22% among individuals over 50 years of age.3 The estimated prevalence of dysphagia in younger people is lower. For example, in a population survey of persons age 30 to 64 years living in the Midwest, the prevalence of dysphagia was 6% to 9%.4 Up to 25% of hospitalized patients and 33% of nursing home residents experience dysphagia.5...