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 226.) 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.
Emergency Actions
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.
History
If the patient’s dysphagia doesn’t suggest airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. 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 assessment
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.
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
In addition to dysphagia, amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig disease, 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
In bulbar paralysis, phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Esophageal cancer
Dysphagia (phases 2 and 3) 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 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 obstruction by foreign body
Esophageal obstruction by foreign body is characterized by sudden onset of dysphagia (phase 2 or 3) as well as gagging, coughing, and esophageal pain. 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 1 hour; radiate to the neck, arm, back, or jaw; and 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 also may be evident. In chemical ingestion, dysphagia may be accompanied by burns, ulcers, or erythema of the lips and mouth.
Esophagitis
Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Dysphagia is accompanied by 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.
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 also may occur.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical lymph nodes.
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
With an oral cavity tumor, painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions. The patient may report an abnormal taste in the mouth, abnormal bleeding from the mouth, or a feeling that dentures no longer fit properly.
Parkinson’s disease
Usually a late symptom of Parkinson’s disease, 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)
Pharyngitis causes painful phase 2 dysphagia of solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat. The patient may report the sensation of a lump in his throat.
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 of liquids results from painful pharyngeal muscle spasms occurring late in this 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.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics of tetanus 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
Procedures
Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When directed against oral cancer, radiation therapy may cause scant salivation and temporary dysphagia.
Special considerations
Stimulate salivation in a patient with dysphagia by talking with him about food, adding a lemon slice or dill pickle to his tray, and providing mouth care before and after meals. Moisten food with a little liquid if the patient has decreased salivation. 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 is producing mucus, avoid uncooked milk products. Consult a therapist to assess the patient’s aspiration risk; swallowing exercises may help decrease this risk.
Prepare the patient for diagnostic evaluation to pinpoint the cause of dysphagia. This may include endoscopy, esophageal manometry, esophagography, and the esophageal acidity test.
Pediatric pointers
In assessing for dysphagia in an infant or a small child, be sure to pay close attention to 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.
Patient counseling
Advise the patient to prepare foods that are easy to swallow. At mealtimes, review measures with the patient to minimize his 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.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Swallowing difficulty
Read excerpts from these other book chapters related to Swallowing difficulty:
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- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Swallowing difficulty
» Next page: Sucking and Swallowing Difficulty (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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