Dysphagia Examination

Dysphagia: Difficulty swallowing with a sensation of food sticking

ID

Specifically note the age of the patient as cancer risk increases with age

Questions to ask

1. Do you have difficulty moving food from your mouth to your throat? (oropharyngeal dysphagia) OR does food get stuck in your throat(known as globus hystericus)? (esophageal dysphagia?)

2. Does food stick immediately (oropharyngeal dysphagia) OR does food stick after swallowing (esophageal dysphagia)?

3. Do you have difficulty with solid foods only (mechanical obstruction) OR solids and liquid foods (neuromuscular disorder)?

4. IS your swallowing difficulty intermittent or has it been progressive?

• intermittent
  • esophageal ring/web
  • diffuse esophageal spasm
• Progressive
  • esophageal stricture
  • esophageal cancer
  • scleroderma (excessive deposits of collagen)
  • achalasia (absence of contraction in the lower half of the esophagus)

5. Any recent ingestion of caustic substances or foreign body?

6. Provoking factors?

7. Relieving factors?

8. Any other symptoms like weight loss, night sweats, blood in sputum?

Review of Systems

General

• weight loss
• appetite
• night sweats
• fever
• fatigue

Respiratory

• coughing
• aspiration - suggests oropharyngeal dysphagia
• halitosis - suggests Zenker's diverticulum

Cardiovascular

• Chest pain - suggests esophageal spasm or esophageal cancer
  • chest pain in esophageal spasm mimics angina as it radiates to back ears neck and jaw

GI

• coughing or choking
  • suggests oropharyngeal dysphagia
• regurgitation from nose
  • suggests oropharyngeal dysphagia
• regurgitation suggests esophageal stricture or achalasia
  • regurgitation is defined as the effortless return of small amounts of gastric or esophageal content into the mouth
• heartburn - suggests esophageal stricture or scleroderma
• odynophagia (pain on swallowing)
• hematemesis
• hoarseness - suggests recurrent laryngeal compression
• slurred speech - muscle incoordination
• dysarthria - soft palate weakness
• hiccups - lower esophageal lesion

PMHx

• Any previous dysphagia
• scleroderma
• cancer
• radiation treatemnt

Family history

• Japanese
• cancer
• scleroderma
• achalasia

Social

• alcohol
• smoking

Physical exam

• oral cavity
  • dentition, lesions, masses
• cranial nerve exam
  • look for evidence of bulbar/pseudobulbar palsy (dysarthria, dysphonia, tongue fasciculations/atrophy)
• cervical lymph nodes
• masses palpable in neck area
• thyroid gland
• skin changes - evidence of connective tissue disease

Tests

• barium swallow
• videofluoroscopy
• upper endoscopy
• fiberoptic nasopharyngeal laryngoscopy
• esophageal manometry