Dysphagia
Dysphagia — difficulty swallowing — is a common symptom that’s usually easy to localize. It may be constant or intermittent and is classified by the phase of swallowing it affects. (See Classifying dysphagia, page 116.)
Among the factors that interfere with swallowing are severe pain, obstruction, abnormal peristalsis, impaired gag reflex, and excessive, scanty, or thick oral secretions.
Dysphagia is the most common — and sometimes the only — symptom of esophageal disorders. However, it may also result from oropharyngeal, respiratory, neurologic, and collagen disorders or from the effects of toxins and treatments. Dysphagia increases the risk of choking and aspiration and may lead to malnutrition and dehydration.
Act Now: If the patient suddenly complains of dysphagia and displays signs of respiratory distress, such as dyspnea and stridor, suspect an airway obstruction and quickly perform abdominal thrusts. Prepare to administer oxygen by mask or nasal cannula, or to assist with endotracheal intubation.
Assessment
History
If the patient’s dysphagia doesn’t suggest airway obstruction, begin a health history. Ask whether swallowing is painful and if so, is the pain constant or intermittent? Have the patient point to the location of the most intense dysphagia. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.
Physical examination
To evaluate the patient’s swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you’re sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient’s mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.
Pediatric pointers
In looking for dysphagia in an infant or a small child, be sure to pay close attention to his sucking and swallowing ability. Coughing, choking, or regurgitation during feeding suggests dysphagia.
Corrosive esophagitis and esophageal obstruction by a foreign body are more common causes of dysphagia in children than in adults. However, dysphagia may also result from congenital anomalies, such as annular stenosis, dysphagia lusoria, and esophageal atresia.
Geriatric pointers
In patients older than age 50, dysphagia is commonly the presenting complaint in cases of head or neck cancer. The incidence of such cancers increases markedly in this age-group.
Medical causes
Achalasia
Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction
Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis (ALS)
Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.
Botulism
Botulism causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.
Bulbar paralysis
Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for both solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Dysphagia lusoria
Dysphagia lusoria is caused by compression of the esophagus by a congenital vascular abnormality (usually an aberrant right subclavian artery arising from the left side of the aortic arch). Phase 3 dysphagia symptoms may occur in childhood or develop later from changes in the aberrant vessel such as arteriosclerosis.
Esophageal cancer
Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.
Esophageal compression (external)
Usually caused by a dilated carotid or aortic aneurysm, external esophageal compression — a rare condition — causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.
Esophageal diverticulum
. Esophageal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.
Esophageal leiomyoma
A relatively rare benign tumor, esophageal leiomyoma may cause phase 3 dysphagia along with retrosternal pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.
Esophageal obstruction by foreign body
Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize esophageal obstruction by foreign body — a potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm
The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture
Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.
Esophagitis
Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.
Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Gastric carcinoma
Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.
Hypocalcemia
Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms may also occur.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in extrinsic laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.
Laryngeal nerve damage
Commonly the result of radical neck surgery, superior laryngeal nerve damage may produce painless phase 2 dysphagia.
Lead poisoning
Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.
Lower esophageal ring
Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body in the lower esophagus, a sensation that may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.
Mediastinitis
Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.
Myasthenia gravis
Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor
Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.
Parkinson’s disease
Usually a late symptom, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, propulsive gait, incontinence, and sexual dysfunction.
Pharyngitis (chronic)
Chronic pharyngitis causes painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat.
Plummer-Vinson syndrome
Plummer-Vinson syndrome causes phase 3 dysphagia for solids in some females with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; smooth, red, sore tongue; dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.
Progressive systemic sclerosis
Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with progressive systemic sclerosis. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness and thickening of the skin that progresses to taut, shiny skin. The patient usually has masklike facies.
Rabies
Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in rabies — a rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of patients it’s responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Syphilis
Rarely, tertiary-stage syphilis causes ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation after meals and heartburn that’s aggravated by lying down or bending over.
Systemic lupus erythematosus (SLE)
SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Medical procedures
Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.
Nursing considerations
Stimulate salivation by talking with the patient about food, adding a lemon slice or dill pickle to his tray, and providing mouth care before and after meals. Moisten his food with a little liquid if salivation is decreased. Administer an anticholinergic or antiemetic to control excess salivation. If he has a weak or absent cough reflex, begin tube feedings or esophageal drips of special formulas.
Consult with the dietitian to select foods with distinct temperatures and textures. The patient should avoid sticky foods, such as bananas and peanut butter. If the patient has mucous production, avoid uncooked milk products. Consult a therapist to assess the patient for his aspiration risk and for swallowing exercises to possibly help decrease his risk. At mealtimes, take measures to minimize the patient’s risk of choking and aspiration. Place the patient in an upright position, and have him flex his neck forward slightly and keep his chin at midline. Instruct the patient to swallow multiple times before taking the next bite or sip. Separate solids from liquids, which are harder to swallow.
Prepare the patient for diagnostic tests including endoscopy, esophageal manometry, esophagography, and esophageal acidity test to pinpoint the cause of dysphagia.
Patient teaching
Advise the patient to consume foods that are easy to swallow. Explain measures he can take to reduce the risk of choking and aspiration, such as positioning during eating and after the meal has been consumed. Encourage the patient’s family or caregiver to take a first aid or cardiopulmonary course that provides techniques for managing choking.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Dysphagia
Read excerpts from these other book chapters related to Dysphagia:
Medical Books Excerpts
- DYSPHAGIA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Dysphagia
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Dysphagia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Dysphagia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Dysphagia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Dysphagia
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Dysphagia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Dysphagia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Dysphagia
» Next page: Dysphagia (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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