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Sometimes subtle and minor symptoms can indicate serious health problems. They shouldn't be underestimated. It's worth being aware of them and contacting a doctor promptly. Especially since they can affect people of all ages.
Dysphagia (Latin phagia - to eat, dys - with difficulty) is a swallowing disorder that makes eating difficult and, in extreme cases, impossible. Contrary to appearances, this symptom is relatively common in many patients and can lead to, among other things, dehydration and malnutrition. Therefore, immediate intervention, including nutritional therapy, is important.
Swallowing consists of a voluntary oral phase and a pharyngeal and esophageal phase, which are independent of human will. The first stage involves breaking up food, chewing it, and mixing it with saliva to allow it to pass easily through the esophagus. The tongue moves the food into the pharynx, then the soft palate contracts and the larynx closes (preventing the reflux of food through the nose and the possible entry of food into the airways). The food passes into the esophagus and, thanks to peristaltic waves, into the stomach. The reflux of food from the stomach into the esophagus is prevented by the efficient function of the esophageal sphincters (lower and upper).
There are two types of dysphagia:
- Oropharyngeal dysphagia (also known as upper, preesophageal dysphagia) - Difficulty occurs before the bite reaches the esophagus, a few seconds after eating. In 80% of cases, the cause is neurological problems, less commonly, neoplastic changes in the head and neck region.
- Esophageal (lower) dysphagia – difficulty occurs when a bite passes through the esophagus. In 85% of cases, it is caused by diseases of the digestive system. Within this type, there are also:
- Mechanical dysphagia – caused by a narrow esophageal lumen and an incorrect ratio of the bite size to the esophageal width. Dysphagia may occur if the esophageal cross-section is less than 25 mm, while dysphagia is a permanent symptom if the esophageal lumen does not exceed 15 mm.
- functional dysphagia - the cause of its occurrence is a disorder of peristalsis (motility), that is, an abnormal movement of a bite through the esophagus into the stomach.
Symptoms of dysphagia and differences between odynophagia and pharyngeal pharyngitis
Patients describe the symptoms of dysphagia as a piece of food stopping, stopping, or sticking to the esophageal wall. They feel as if an obstruction has been created in the food's path to the stomach. They may also experience difficulty initiating the act of swallowing (this applies to oropharyngeal dysphagia).
Dysphagia may also be accompanied by coughing during swallowing or nighttime coughing, regurgitation of food through the nose, hoarseness (persistent hoarseness without a concomitant cold), regurgitation of undigested food, noisy swallowing, or bad breath. At the same time, it is worth noting that patients do not feel pain during the swallowing process. The pain of swallowing is called odynophagia. Dysphagia and odynophagia can occur simultaneously or independently.
Patients have no difficulty other than swallowing. Pharyngeal congestion, formerly known as hysterical globus (globus hystericus), usually refers to a sensation of congestion, tickling, or a foreign body in the throat. However, this symptom does not interfere with swallowing and is usually not associated with other symptoms. A diagnosis of pharyngeal congestion is only made after excluding organic pathologies in the pharynx and esophagus.
Diagnosis of dysphagia
When making a diagnosis, it is important to take an appropriate medical history and determine what foods are causing dysphagia, how long it has lasted, and whether it came on suddenly. If this is the case, it may indicate the formation of a ring in the esophagus, such as a Schatzki ring—a fibrous ring near the junction of the esophagus and the stomach. If this symptom worsens, difficulty swallowing solid food increases, it may indicate a malignant tumor or stenosis associated with reflux disease. As well as the presence of changes in the esophagus that narrow its lumen, these include benign, malignant, inflammatory, post-radiation ulcerative changes, diverticula, and intraesophageal rings and membranes.
A thorough medical history allows for a correct diagnosis of dysphagia in up to 80% of cases. Dysphagia associated with swallowing only solid foods likely indicates a mechanical obstruction. On the other hand, dysphagia associated with swallowing both solid and liquid foods may indicate muscle and nerve disorders.
In addition, when making a diagnosis, attention should be paid to the presence of additional symptoms, i.e. burning in the esophagus, cough, regurgitation of food depending on the position of the body, or recurrent pneumonia.
One of the screening tests that can be used to identify patients with dysphagia is the bed-side water swallow test (BSE) or test substance (e.g., gugging swallow screen cast (GUSS) or volume viscosity swallow test (V-VST)) in various volumes. The next step is the aspiration risk assessment test, assessed according to the PAS scale—the degree of contrast penetration into the airway—or the FEDSS scale—the risk of repeat intubation.
Causes of dysphagia
The causes of dysphagia are very complex and can affect many aspects of the human body's functioning. These include:
- Diseases of the striated muscles of the esophagus,
- neurological diseases (e.g. stroke, Parkinson's disease, multiple sclerosis, polyneuritis) - this type of dysphagia is called neurological dysphagia,
- various pathologies in the mouth and throat, neck and throat,
- Abnormalities in the function of the upper esophageal sphincter,
- enlarged lymph nodes,
- Thyroid diseases,
- Changes in the osteoarticular system of the neck,
- Scleroderma and associated skin changes,
- neuromuscular diseases (mythenia, botulism),
- (muscular dystrophy, dermatomyositis, in the course of sarcoidosis, amyloidosis, in metabolic or steroid myopathies),
- difficult-to-treat infections in AIDS patients and the occurrence of Kapusi sarcomas or lymphomas during the course of this disease,
- intentionally or accidentally swallowed foreign body
- Esophageal motility disorders,
- Damage to the structure of the esophagus as a result of intubation, disease, burns, surgery or adjuvant treatment (radiotherapy),
- Medications: cholinolytics (butyl bromide hyoscine), opioids, tricyclics, antidepressants, muscle relaxants, anxiolytics.
In addition, sudden weight loss, age over 50, alcohol abuse and smoking increase the risk of dysphagia.
Complications of dysphagia
The most serious complications of dysphagia are aspiration or choking and aspiration pneumonia. Other complications may include increased patient intubation and tracheostomy (especially in intensive care units). Furthermore, dysphagia increases the patient's risk of death. Other common complications of dysphagia and the resulting reduced food intake include malnutrition and dehydration, resulting in prolonged hospital stay, increased treatment costs, poorer prognosis, and more frequent discharges from nursing and treatment facilities.
Treatment of dysphagia
The treatment of dysphagia aims to prevent aspiration (choking, accidental inhalation while drinking or eating) and its complications (including acute airway obstruction). Treatment is adaptive, compensatory, or rehabilitative and depends on the severity of the swallowing difficulty. A slight dietary change is sufficient. In more severe cases, nasal lubrication or the use of artificial saliva may be necessary.
In contrast to other forms of dysphagia, neurogenic dysphagia can result in an overproduction of saliva, which can cause choking, which in extreme cases can only be prevented by surgery. Another method for treating this type of symptom is neurostimulation. For example, with the PES method, a 10-minute stimulation session is performed for 3 days.
Under the supervision of a physiotherapist, you can also influence the stimulation of the swallowing reflex during a meal by changing the posture and positioning the head in relation to the body.
It is also helpful to stop smoking and drinking coffee, as they negatively affect the swallowing process, for example, causing the lower esophageal sphincter to relax too much.
Drug treatment of dysphagia is only carried out in the presence of gastroesophageal reflux disease or disorders of the esophageal sphincter tone in the context of other diseases.
In the case of dysphagia caused by morphological changes, endoscopic procedures for lumen dilation or prosthetics of the esophagus or brachytherapy in the case of neoplastic lesions are used.
Nutritional therapy for dysphagia
Dietary changes in patients with dysphagia depend on the type of food intolerant. If we are dealing with the occurrence of dysphagia as a result of the consumption of liquid foods, the diet should be concentrated. In this case, the preparations available on the market that change the consistency of liquids and form a kind of jelly work well. Concentrating juices with potato flour, for example, or simply making jelly also works well in such cases. Patients in whom dysphagia occurs as a result of eating solid foods should eat mixed, crushed foods with a porridge-like consistency. In extreme cases, e.g. difficulty swallowing, nutrition, e.g. via a gastric tube, is necessary regardless of the consistency of the food. This is necessary to prevent malnutrition and dehydration and their consequences, e.g. prolonged convalescence.
The food served should stimulate the receptors in the oral cavity and support swallowing reflexes. The food served to the patient should be properly seasoned and aromatic to further stimulate peristaltic reflexes through smell. Caution: For patients with dysphagia resulting from changes in the esophagus, foods should be aromatic but at the same time not irritate the esophageal walls. This approach is also necessary for swallowing difficulties after radiation therapy, as overly seasoned foods can irritate the patient and trigger vomiting, which further increases the risk of malnutrition. In any case, the temperature of the food should be moderate.
Peristaltic movements by sucking on ice cubes, frozen fruit or chewing gum can also be helpful.
Nutridrinks and other high-osmolar products allow you to provide more calories in a small volume and also have the consistency of loose jelly, making them ideal for people with dysphagia.
Summary
Dysphagia is the medical term for a mechanical, functional, neurological, or structural disorder of swallowing. Prolonged difficulty swallowing both solid and liquid foods increases the risk of, among other things, aspiration pneumonia, malnutrition, dehydration, and a worse prognosis. Treatment is based on dietary modification, concentration of liquid foods, and mixing and grinding of solid foods. Sucking on ice cubes, frozen fruit , or chewing gum may help. If the patient is unable to absorb the appropriate amount of calories from food, introducing high-osmolality supplements may be helpful.
