Dysphagia

Dysphagia is the medical term to indicate problems with swallowing, or rather difficulty in the passage of food and beverages from the oral cavity to the stomach, due to structural anomaly or oesophageal motility disorders. Dysphagia can be manifested as difficulty to swallow, drink, chew, eat, suck, control saliva, take medicine or protect the airways. It is usually correlated with underlying medical or physical conditions but can occasionally have psychological causes.

 

In Italy, there are more than 6 million patients suffering from dysphagia. The condition affects above all the elderly, but it is also common among adults, affecting 45% of people over the age of 75, and 20% of people over the age of 50. 60% of affected patients are resident in nursing homes or receive Home Care services, and the majority have neurodegenerative and cardiovascular conditions, or have suffered from strokes or tumours.

Sufferers of dysphagia can also be subject to malnutrition and dehydration, as well as problems relative to quality of life and loss of self-esteem, safety, ability to work and to enjoy themselves. Therefore, as a whole, dysphagia is a debilitating condition with social consequences for both the person affected and their family.

There are two main types of dysphagia:

Oropharyngeal dysphagia: difficulty in forming a bolus of food, in initiating the swallowing process and passing food from the mouth to the oesophagus.

Oesophageal dysphagia: difficulty encountered in the passage of food along the oesophagus to the stomach.

Dysphagia is often caused by a condition, syndrome or illness that effects the nerves and muscles of the tongue, mouth or throat, leading to problems of coordination and/or control of swallowing.

 

The main causes of dysphagia may be:

• Neurological: Trauma to the head, stroke, Alzheimer’s disease, Parkinson’s disease, Multiple sclerosis, Amyotrophic lateral sclerosis and Cerebral paralysis.
• Mechanical: Oesophageal stricture or spasm, neoplasms in the oesophagus and head-neck area, pathologies affecting the oral cavity.
• Iatrogenesis: Radiotherapy, following oral cavity surgery, patients with structural damage to the muscles in the oesophageal wall.
• Age: the elderly are subject to a progressive alteration in nervous and muscular function.

When a person has a problem swallowing, it can emerge in many different ways, both through typical physical and behavioural manifestations. The seriousness of the symptoms depends in part on the duration of the oesophageal obstruction caused by food or drinks.

 

The symptoms related to dysphagia include:

• Coughing during meals
• A sense of suffocation when swallowing
• Nasopharyngeal regurgitation
• Alteration of speech
• A feeling of globus or “swelling in the throat”
• Slow and difficult swallowing
• Lack of appetite
• A feeling of weakness
• Loss of weight
• Recurrent pneumonia

Many patients are unaware that they suffer from problems with swallowing. This increases the risk of the following disturbances:

• aspiration pneumonia (the accidental inhaling of saliva or food particles)
• malnutrition (an insufficiency of nutrients that are vital for good health)
• dehydration (insufficient assumption of liquids leading to a shortage of water in the body).

Malnutrition and dehydration, aspiration pneumonia, general health problems, chronic lung disease, suffocation and even death can all be caused by dysphagia. Morbidity related to dysphagia is one of the main worries.

Adults with dysphagia can also suffer from a lack of interest in, or loss of pleasure from, eating or drinking, or embarrassment or isolation in social situations that involve eating.

Dysphagia may increase the workload of the caregiver and require significant changes in the lifestyle of the patient and their family.

Dysphagia is an alarming symptom, particularly if it has recently developed in an elderly patient and is getting rapidly worse. As case history and objective examinations alone may not be sufficient in providing diagnosis in the case of silent aspiration, further diagnostic tests such as the following may be necessary:

1. Esophagogastroduodenoscopy is essential in confirming or excluding structural modifications to the oesophagus, the junction between the oesophagus and the stomach, and of the stomach itself through histological examination.
2. An X-ray with barium is carried out to identify the cause of oropharyngeal dysphagia (a fluoroscopic examination of the swallowing process) and conditions resulting in oesophageal motility, such as Zenker’s diverticulum, achalasia, jackhammer oesophagus and hiatus hernia.
3. High-resolution oesophageal motility study with or without a study of impedance, may confirm conditions affecting oesophageal motility.
4. Ambulatory monitoring of oesophageal pH with or without a study of impedance can be used to exclude  gastroesophageal reflux disease. It also provides information on the association between dysphagia and exposition of the oesophagus to acid.

Dysphagia is an alarming symptom, particularly if it has recently developed in an elderly patient and is getting rapidly worse. As case history and objective examinations alone may not be sufficient in providing diagnosis in the case of silent aspiration, further diagnostic tests such as the following may be necessary:

1. Esophagogastroduodenoscopy is essential in confirming or excluding structural modifications to the oesophagus, the junction between the oesophagus and the stomach, and of the stomach itself through histological examination.
2. An X-ray with barium is carried out to identify the cause of oropharyngeal dysphagia (a fluoroscopic examination of the swallowing process) and conditions resulting in oesophageal motility, such as Zenker’s diverticulum, achalasia, jackhammer oesophagus and hiatus hernia.
3. High-resolution oesophageal motility study with or without a study of impedance, may confirm conditions affecting oesophageal motility.
4. Ambulatory monitoring of oesophageal pH with or without a study of impedance can be used to exclude  gastroesophageal reflux disease. It also provides information on the association between dysphagia and exposition of the oesophagus to acid.