A patient presents with difficulty feeding for the past month. Specifically, she states that she is “unable” to swallow. How do we perform the bedside examination so as to take this presentation to the highest degree of resolution?
Swallowing can be divided into 2 processes: oropharyngeal and esophageal.
The oropharyngeal process moves the food bolus from the back of the tongue to the pharynx, where the pharynx squeezes it into the upper esophagus. This event involves the soft palate closing of the nasopharynx, the epiglottis closing of the tracheal entrance, and the upper esophageal sphincter transiently relaxing to accommodate the food bolus. This is a complex neurological event, and oropharyngeal dysphagia is usually caused by a neurological disease. Telltale signs include nasal and tracheal aspiration, as well as inability to propel food out of the pharynx.
The esophageal process moves food from the upper esophageal sphincter (cricopharyngeus) to the lower esophageal sphincter. Disruption can be anatomic (obstruction) or physiologic (motility). It presents with the feeling that food gets stuck in the esophagus. Patients feel these symptoms in the chest.
Dysphagia to solids only (such as chewy meats) signifies an anatomic obstruction. Gastroenterologists use marshmallows to bring this out, and call it a “viscous swallow.” Typical causes of anatomic obstruction include stricture, ring, or cancer.
Dysphagia to liquids and solids signifies a physiologic motility disorder. These can be localized to the lower esophageal sphincter, such as achalasia, or can be diffuse, such as diffuse esophageal spasm. Motility orders can also be secondary to inflammation, such as in gastroesophageal reflux disease.
By clarifying which part of the swallow process is disordered as well as noting whether liquids are affected helps considerably narrow the differential diagnosis of dysphagia.
-Inability to swallow or aspiration indicates oropharyngeal dysphagia, and is usually neurologic.
-Dysphagia to solids indicates obstruction.
-Dysphagia to liquids and solids indicates a motility disorder.