Other motility disorders P.E. Hyman · T.

Zangen Dysphagia

햲
Dysphagia
38 Medical and feeding history
Physical examination 햳

Difficulty initiating swallows Food stops in or sticks to the esophagus

associated with coughing or choking after swallowing

Oropharyngeal dysphagia 햳 햴 Esophageal dysphagia 햵

Videofluoroscopy 햶 햷 Upper GI endoscopy with biopsies

(modified barium swallow)

Mucosal lesion 햸 Structural lesion 햹 Normal

Barium
swallow

Normal

Anatomic Neurological Primary motility Reflux symptoms

abnormalities abnormalities disorder 햺 Trial of PPI 햻

Dysphagia Dysphagia Manometry

improves the same

Normal Motility disorder 햽

Developmental Cleft palate Hypoxic brain damage Oropharyngeal Reflux Stenosis Reflux Psychological Functional Achalasia
dysphagia Craniofacial Myasthenia gravis incoordination esophagitis Stricture disease dysphagia 햾 dysphagia 햿 Esophageal spasm
syndromes Congenital myotonic Cricopharyngeal EoE Web Scleroderma
dystrophy achalasia Infectious Foreign body Dysautonomia
Head trauma esophagitis Tumor

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Neurodegenerative Vascular ring

Verlag S. KARGER AG BASEL

Spontaneous disorders Dermatologic
resolution Chiari malformation disorder

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 햲 — Dysphagia is defined as difficulty in swallowing. Accurate
쏹 햷 — Impaired oropharyngeal swallowing may be associated
pain complaints are difficult to elicit in infants, young children
and children with limited cognitive abilities. Untreated dyspha-
gia may be associated with food refusal, FTT, aspiration pneu-
monias and/or inability to maintain proper nutrition and hydra-
tion.
햳 — Impaired swallowing can be due to oropharyngeal or
쏹 disorder are associated with dysphagia in a few children.
esophageal dysfunction. History and physical examination of
anatomic and neurologic abnormalities should explore for non-
esophageal causes. Symptoms of choking, cough, gagging, cya-
nosis, posturing of head and neck during eating, or food aver-
sion and feeding difficulties are suggestive of swallowing disor-
ders. Impaired neuromuscular coordination of swallowing
(cerebral palsy, congenital myotonic dystrophy, neurodegenera-
tive disorders, myasthenia gravis, Chiari malformation, head
trauma), abnormalities of the head and neck (mass, goiter) or
abnormalities of the oral cavity (macroglossia, cleft palate,
micrognathia) are supportive of oropharyngeal dysphagia.
햴 — Oropharyngeal dysphagia can be a transient phenome-
쏹 phagia (dysphagia lusoria). Evaluations for structural lesions
non in infants upon the introduction of solid food. It is usually
associated with mild motor developmental delay or sensory
hypersensitivity. Diagnostic procedures are seldom indicated,
and the symptoms resolve spontaneously.
햵 — Esophageal dysphagia occurs with solid food only, or
쏹 feeding difficulties at birth or till 6 months of age. Diagnosis is
with both solids and liquids. The associated symptom of odyno-
phagia is highly suggestive of esophageal ulceration.
햶 — Videofluoroscopy, or modified barium swallow, is the
쏹 햻 — In the absence of structural or mucosal abnormalities,
procedure of choice for evaluating the patient with impaired
swallowing. Swallowing is assessed by visualizing the passage
of barium-impregnated liquids, pastes and pureed foods
through the oral cavity, pharynx and esophagus. Fluoroscopy
provides objective evidence of oral and pharyngeal dysfunction
and detects aspiration. Videofluoroscopy aids in assessing the
bolus characteristics (size and consistency) that make food safe
to swallow.
쏹 햽 — If no structural or mucosal abnormality is found, manom-
with aspiration and chronic airway disease as well as recurrent
or chronic pneumonia. In case of proven aspiration, oral feeding
is replaced by enteral tube feeding to ‘bypass’ swallowing. In
some cases, swallowing may improve (developmental improve-
ment or rehabilitation after trauma) and oral feeding can be re-
sumed.
햸 — Esophageal mucosal lesions often present as dysphagia.
쏹 Esophageal motility disorders occur in cases of esophageal in-
Upper GI endoscopy is the optimal study to identify mucosal
lesions. Peptic esophagitis due to esophageal acid exposure,
EoE due to food allergy and infectious esophagitis (CMV, can-
dida, herpes) are the most common causes of esophageal mu-
cosal inflammation.
햹 — Esophageal intrinsic narrowing may be caused by con-
쏹 cur as part of an anxiety disorder. Finally, dysphagia may be the
genital stenosis or web, acquired strictures (peptic, eosinophilic,
caustic ingestion, dermatological disorders), postfundoplication
and tumors or after surgical repair for esophageal atresia. Ex-
trinsic compression by a vascular ring may also present as dys-
include upper GI endoscopy and barium swallow, even with no
endoscopic abnormality.
햺 — Isolated cricopharyngeal dysfunction is a rare motility
쏹
disorder in infants and children. Most patients present with
aided by barium swallow and manometry. Clinical improvement
may occur spontaneously or after cricopharyngeal dilatations.
쏹 Spechler SJ: AGA technical review on treatment of patients
concomitant symptoms of heartburn or regurgitation suggest
that esophageal sensitivity to acid may be the cause of the dys-
phagia. Resolution of the dysphagia with PPI therapy implies
that the dysphagia was a manifestation of reflux disease.
쏹
etry is indicated. Most nonstructural causes of esophageal dys-
phagia are due to abnormal esophageal motility. There are pri-
mary esophageal motility disorders: achalasia is probably the
best known of these and is well defined by the absent esopha-
geal peristalsis and impaired deglutitive LES relaxation. Diffuse
or distal esophageal spasm and nonspecific esophageal motility
volvement in systemic diseases, e.g. familial dysautonomia,
scleroderma, CIP and graft-versus-host disease.
햾 — Several psychiatric conditions are associated with dys-
쏹
phagia. Dysphagia may occur as a phobia following a frighten-
ing, sensitizing or choking experience with food. It may also oc-
presentation of an eating disorder, not otherwise specified.
햿 — The Rome criteria for functional dysphagia must be ful-
쏹
filled for the preceeding 3 months, with symptom onset at least
6 months prior to diagnosis, and include the following: (1)
Sense of solid and/or liquid foods sticking to, lodging in, or
passing abnormally through the esophagus. (2) Absence of evi-
dence that GER is the cause. (3) Absence of achalasia.
Selected reading
Owen W: ABC of the upper gastrointestinal tract. Dysphagia.
BMJ 2001; 323: 850–853.
with dysphagia caused by benign disorders of the distal
esophagus. Gastroenterology 1999; 117: 233–254.
Tutor JD, Gosa MM: Dysphagia and aspiration in children.
Pediatr Pulmonol 2012; 47: 321–337.

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Other motility disorders P.E. Hyman · T. Zangen Dysphagia