Dysphagia is defined as the presence of difficulty in swallowing. It is a common problem (10 million Americans being evaluated each year). Recent studies in Europe suggest that over half of older persons with dysphagia are inadequately evaluated and treated.

The swallowing process consists of a programmed dynamic sequence of muscular contraction and relaxation that can be divided into three phases based on the location: the oral, oro-pharyngeal, and esophageal phase. It is shown schematically in Fig. 1.

Dysphagia can be divided into two categories based on the location of the problem. The term "oropharyngeal dysphagia" is used if the problem arises prior to the bolus reaching the upper esophagus, and "esophageal dysphagia" is used if the problem arises afterwards. The most common causes of oropharyngeal dysphagia in young people include inflammatory muscle diseases, webs and rings. In older persons, oropharyngeal dysphagia is usually caused by central nervous system lesions including strokes, Parkinson's and dementias. Esophageal dysphagia is commonly caused by reflux esophagitis, motility disorders and tumors. A list of the most common causes of dysphagia is provided in Table 1.

Table 1. Common Causes of Dysphagia.

OROPHARYNGEAL	ESOPHAGEAL
Obstructive/Mechanical	Intrinsic Obstructive Lesion
Head or neck cancer	Benign tumors
Zenker diverticulum	Malignant tumors
Post-cricoid cartilage web	Webs and rings
Goiter	Strictures
Cervical osteophytes	Foreign bodies
Post-surgical/radiation stenosis
Infections (tonsilar enlargement/abscess)	Extrinsic Obstructive Lesion
Caustic esophagitis	Mediastinal mass
	Aberrant subclavius
Neurogenic	Tortuous aorta
Cerebrovascular accidents	Enlarged right atrium
Cerebral tumor
Head trauma	Neuromuscular (motility)
Alzheimer's disease	Achalasia
Parkinson's disease	Diffuse esophageal spasm
Multiple sclerosis	Lower esophageal sphincter hypertension
Amyotropic lateral sclerosis	Chagas Disease
Bulbar palsy	Scleroderma
Pseudobulbar palsy	Amyloidosis
Poliomyelitis
	Diabetes mellitus
Neuromuscular Junction	Radiation esophagitis
Myasthenia Gravis
Eaton-Lambert Syndrome
Botulism
Muscular
Myotonic dystrophy
Occulopharyngeal dystrophy
Polymyositis/Dermatomyocitis
Thyroid myopathy (hyper or hypo)
Steroid Myopathy
Amyloidosis
Upper Esophageal Sphincter (UES)
Hypertensive UES
Abnormal relaxation of the UES
Abnormal opening of the UES

An accurate history, covering the location of discomfort, time of onset, accompanying symptoms, type of food and progression over time, is most important in the diagnosis. Oropharyngeal dysphagia typically causes difficulty in swallowing liquids. The patient complains of food "sticking" in the throat, usually above the sternal notch. It happens immediately after swallowing and may be accompanied by coughing, choking or nasal regurgitation. When the onset of these symptoms is acute, it may suggest a stroke; if it is progressive, it may suggest head or neck tumor.

Esophageal dysphagia typically presents with discomfort in the substernal region. However, pain may be referred to the suprasternal area and, as a result, confused with oropharyngeal dysphagia. Discomfort usually presents shortly after swallowing and, depending on the etiology, may be present with solids only, if it is obstructive, or both solids and liquids, if it is motility related. The presence of angina-like chest pain usually suggests esophageal spasm or gastro-esophageal reflux. Pain otherwise referred to as odynophagia usually reflects esophagitis secondary to infections, chemical burn or "pill-related".

The algorithm in Figure 2 can be used to classify patients and chose the appropriate diagnostic test.

The physical examination should not only be focused on the local organs involved in the swallowing process but also be expanded to include signs of systemic disease and possible sequelae of dysphagia (e.g., aspiration pneumonia and malnutrition).

Head and neck examination may reveal signs of previous surgery, radiation or tracheostomy. A good oro-pharyngeal examination should be performed to evaluate dentition, the tongue, oropharynx, hypopharynx and vocal cords. The presence of erythema and inflammation of the vocal cord may reflect acid reflux disease. Neck examination should be performed looking for masses, lymphadenopathy or a goiter. Contrary to common belief, the gag reflex does not predict pharyngeal dysfunction or aspiration risk. The gag reflex is actually absent in 20-40% of healthy adults, especially in the older patient. A good neurologic examination, including a detailed cranial nerve examination, is essential.

Lab tests for myasthenia gravis and thyroid disease, for example, can help lead to the diagnosis of medical conditions that can produce dysphagia. Findings from the history and physical examination will determine the choice of the initial diagnostic modality: Video Fluoroscopic Swallowing Study (VFSS), barium-contrast esophagogram, upper endoscopy or manometry.

VFSS, also known as "modified barium swallow", is the "gold standard" for diagnosing oropharyngeal dysphagia.. It is a dynamic test in which the patient is asked to swallow a variety of food items of different consistencies covered with barium. A video fluoroscopic recording is made in both antero-posterior and lateral views. VFSS allows for observation of bolus progress throughout the different stages of the swallowing process. The dynamic nature of this study provides an opportunity to evaluate the response to certain correctional techniques (e.g., chin tucking) during the study. VFSS requires the cooperation of an alert patient, which is the most limiting factor to performing VFSS.
When VFSS is not possible, because of a high risk of aspiration or if the patient can not be transported to the fluoroscopy suite, other studies are suggested.

Video Endoscopic Swallowing Study (VESS) allows direct visualization of the oropharynx in action with and without swallowing, using a fiberoptic scope inserted nasally. The addition of methylene blue water may improve the sensitivity of this test.

Oropharyngeal manometry is considered difficult to perform because of the rapidly changing pressures in the pharyngeal area and the low tolerance to the placement of the catheter. Newer computerized techniques, utilizing thinner catheters, can provide invaluable information to diagnose UES abnormalities. Performing videofluoroscopy concurrently with manometry is known as 'manofluorography' and provides additive information if done properly.

Barium-Contrast Esophagogram (Barium Swallow) is the initial recommended test if esophageal dysphagia is suspected. The patient is asked to drink liquid barium (and, sometimes. barium coated marshmallows) while pictures are taken in both upright and supine positions. Barium-contrast esophagogram identifies most cases of mechanical obstruction, such as strictures, rings and webs.

If the radiographic studies are inconclusive, esophagoscopy is indicated. It is superior to barium swallow for evaluating small lesions of the mucosa, and sequelae of acid reflux disease. Barium swallow is, however, complementary for diagnosing intramural lesions and extrinsic obstruction, and is almost of no value in diagnosing motility disorders. Endoscopy provides the opportunity for therapeutic intervention if necessary.

Esophageal Manometry is based on the principle of recording pressures throughout the esophageal lumen using a solid-state or perfusion technique. It gives a recording of the peristaltic contractions in the esophageal body including its duration, velocity and amplitude. Manometry is indicated when an esophageal etiology for dysphagia is suspected despite inconclusive barium swallow and endoscopic evaluation.

If a reversible or treatable cause of oropharyngeal dysphagia is identified, it should be corrected. This includes cases of thyroid disease, myasthenia gravis and other potentially treatable conditions. Patients with structural lesions (e.g., tumor or Zenker's) should be referred for surgery. In patients with dysphagia, there is a need to identify whether or not the patient can obtain adequate nutrition through the oral route and how high the risk of aspiration pneumonia appears to be. If ability to obtain adequate nutrition is limited or the aspiration risk is high, non-oral feeding, usually through a gastreostomy tube, should be considered. Surgical treatments, such as cricopharyngeal myotomy, have been successful in up to 60% of cases but their use remains controversial.

Numerous swallowing therapy techniques have been developed. In general they can be divided into: dietary modifications, swallowing maneuvers, postural adjustment, facilitatory techniques such as strengthening exercises, biofeedback, thermal and gustatory stimulation.

In general, management of dysphagia secondary to problems in the distal esophagus is dependent on the endoscopy findings and, in the case of achalasia, on the results of manometry. When no lesion is present, the treatment of choice for esophageal motility disorders is cisapride or domperidone. If these agents fail, dilatation to between 40 F and 54 F should be undertaken. Reflux esophagus is first treated with anti-reflux therapy (proton pump inhibitors, cisapride or domperidone and, when indicated, funduplication) and if that fails dilation. Infections should be treated with the appropriate chemotherapy. Tumors require surgery. Patients with achalasia who are good operative risks should receive surgery. Pneumatic dilation, once an acceptable treatment modality, is rarely used now because of the risk of perforation. If the patient is a poor operative risk, medical therapy with nitrates and/or calcium channel blockers can be utilized. If this is unsuccessful, bougienage with a 45 F to 60 F dilator can be tried. Other therapies include injection with botulinium toxin, myotomy or pneumatic dilatation.

Management options for different conditions causing esophageal dysphagia are summarized in Table 2.

Table 2. Management Options for Esophageal Dysphagia.

Condition	Conservative treatment	Invasive treatment
Diffuse esophageal spasms	Nitrate, calcium channel blockers	Serial dilations or longitudinal myotomy
Achalasia	Soft food, anticholinergics, calcium channel blockers	Dilation, botulinium toxin injections, Hellers myotomy
Scleroderma	Anti-reflux, systemic medical management of scleroderma	None
GERD	Anti-reflux drugs (H2 blockers, Proton pump inhibitors) and prokinetic agents (cisapride)	Fundoplication
Infectious esophagitis	Antibiotics (nystatin, acyclovir,..)	None
Pharyngoesophageal (Zenker_s) diverticulum	None	Endoscopic or external repair in addition to cricopharyngeal myotomy
Schatzki_s ring	Soft food	Dilation

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