Generally defined as difficulty in swallowing (or the sensation of difficulty in swallowing), dysphagia reflects an esophageal or pharyngeal transport disorder, either from anatomical malformations or from a disruption of the physiological events in swallowing. Dysphagia can be subdivided into the following two distinct types, which can occur independently.

• Oropharyngeal dysphagia: Difficulty initiating the act of swallowing, of moving food from the mouth to the upper esophagus (generally from abnormalities of the pharynx and upper esophageal sphincter)
• Esophageal dysphagia: Difficulty moving food through the esophagus

The lifetime incidence of dysphagia is less than 10%. Although all ages are affected, the prevalence increases with age. No sex differentiation.

The causes of oropharyngeal dysphagia (dysphagia for solids or liquids) include the following.

• CNS: cerebrovascular accident (CVA), Parkinson's disease, brainstem tumors
• Muscle: myasthenia, polymyositis, thyroid disease, systemic lupus erythematosus
• Structural: web, Zenker's diverticulum, extrinsic compression

The causes of esophageal dysphagia include the following.

• Dysphagia for solids only, intermittent: webs, rings, diverticulum, esophagitis
• Solids only, continuous/progressive: carcinoma (particularly under age 40), stricture
• Solids and liquids: motility disorder such as diffuse esophageal spasm, tumor, stricture, esophagitis

Dysphagia in children usually indicates the following.

• Congenital malformations: esophageal atresia, choanal atresia
• Acquired malformations: corrosive or herpetic esophagitis
• Neuromuscular/neurologic conditions: cerebral palsy, muscular dystrophy
• GERD

Dysphagia in adults usually indicates the following.

• Structural: tumors (benign and malignant), strictures, rings and webs, extrinsic compression
• Neuromuscular: achalasia, diffuse esophageal spasm, scleroderma, myasthenia gravis
• Gastroesophageal reflux disease (GERD)

• Smoking
• Recurrent or chronic GERD
• Medications (such as quinine, potassium chloride, vitamin C, tetracycline, NSAIDs)
• Poor dentition
• Ill-functioning dentures
• Excessive alcohol consumption
• Achalasia
• Esophageal cancer
• Plummer-Vinson syndrome
• Barrett's mucosa
• Hereditary or congenital malformations

Oropharyngeal dysphagia is characterized by the following.

• Difficulty initiating swallowing
• Inability to move food into the esophagus
• Choking or aspiration while swallowing
• Coughing while swallowing
• Regurgitation of liquid through the nose
• Aspiration with swallowing
• Weak voice
• Weight loss

Esophageal dysphagia is characterized by the following.

• Pressure sensation in mid-chest
• Sensation of food stuck in the esophagus
• Retrosternal fullness after swallowing
• Weight loss
• Chest pain and other GERD symptoms
• Extended period of time required for eating

• Cardiac-associated chest pain
• Globus hystericus
• Scleroderma

Because dysphagia is symptomatic of a structural or functional abnormality, determining the etiology is essential for effective treatment. Avoid dismissing the symptom as psychosomatic or "globus hystericus." Consultation with a gastroenterologist is advised.

Determine precisely where the patient's symptoms are felt; whether symptoms appear with solids, liquids, or both; if the symptoms are intermittent or progressive. Also, question patients about length of time spent eating (i.e., unconsciously chewing food thoroughly). For infants/children, observe sucking and eating practices.

During evaluation, consider the following.

• Esophageal patency, inflammation
• Airway function
• Pulmonary function
• Cardiac disease
• Nutritional status
• Evidence of aspiration pneumonia
• Symptoms of heartburn

• Mass lesion, including squamous cell carcinoma and adenocarcinoma
• Barrett's metaplasia
• Fibrous tissue from a ring, web, or stricture
• Heterotopic gastric mucosa
• Acute or chronic inflammatory change
• Deformities or scars

For infants and children:

• X ray of neck, chest
• Contrast X ray

For adults:

• X ray of neck, chest, abdomen
• Barium swallow (cine/video esophagogram)
• Contrast X ray: esophagogram, cine-esophagogram, modified cine-esophagogram
• CT scan

In addition to physical assessment and history, these special tests may be done:

• Esophagoscopy: particularly relevant for patients with persistent difficulty swallowing solid food. Disruption of webs and rings during endoscopy can be therapeutic.
• Esophageal manometry: preferred procedure for esophageal motor function evaluation (affected by anticholinergics, calcium-channel blockers, nitrates, prokinetics, sedatives)
• Endoscopic ultrasonography: to diagnose and stage benign and malignant esophageal neoplasms
• Infants and children: nasogastric tube assessment of esophagus patency

Outpatient care is appropriate for patients capable of maintaining nutrition and with low risk of complications. Hospitalization may be necessary for infants and children, and for adults with total or near-total obstruction of the esophageal lumen.

Treatment can include drug therapies, esophageal dilatation, and surgery.

Check manufacturers' profiles for possible drug interactions. Liquid forms of medications may be necessary.

For spasms:

• Nitrates: nitroglycerin, isosorbide (contraindications: early myocardial infarction, severe anemia, increased intracranial pressure)
• Anticholinergics: dicyclomine (Bentyl) or hyoscyamine sulfate (Lepsin) (contraindications: obstructive uropathy, glaucoma, myasthenia gravis, achalasia)
• Calcium-channel blockers: nifedipine (Procardia), diltiazem (Cardizem)
• Sedatives/antidepressants: diazepam (Valium), trazodone (Desyrel), doxepin (Sinequan)
• Smooth-muscle relaxants: hydralazine

For esophagitis:

• H2-blockers: cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), famotidine (Pepcid)
• Proton-pump inhibitors (for failure of H2-blockers or as initial therapy): omeprazole (Prilosec), lansoprazole (Prevacid)
• Prokinetic agents: metoclopramide (Reglan), cisapride (Propulsid); adjunct to acid-suppressive therapy

Herbs can be very effective at decreasing spasms and healing esophagitis. Homeopathics could be used concurrently for symptomatic relief.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Licorice (Glycyrrhiza glabra): an anti-inflammatory, antispasmodic, and analgesic specific for the gastrointestinal tract. Glycyrrhetinic acid has been shown in studies to aid healing of gastric, peptic, and mouth ulcers. In patients with hypertension, use deglycerinated licorice to prevent aggravating hypertension. Prolonged use may lead to pseudoaldosteronism, which resolves with discontinuation of the herb. The dose is 380 to 1,140 mg/day. Chewable lozenges may be the best form of licorice for treating GERD.
• Slippery elm (Ulmus fulva): demulcent (protects irritated tissues and promotes their healing); dose is 60 to 320 mg/day. One tsp. powder may be mixed with water tid to qid.

In addition, a combination of four of the following herbs may be used as either a tea or tincture. Use equal parts of the herbs, either 1 tsp. of each per cup of water and steep 10 minutes tid, or equal parts of tincture 30 to 60 drops tid.

• Valerian (Valeriana officinalis): bitter, sedative, especially where there is anxiety and/or depression and poor digestion
• Wild yam (Dioscorea villosa): antispasmodic, anti-inflammatory, especially where there is fatigue from long-term stress or maldigestion
• St. John's wort (Hypericum perforatum): analgesic, antidepressant, historically used to treat adhesions, especially where there is anxiety and/or pain
• Skullcap (Scutellaria lateriflora): antispasmodic, sedative, nervine, especially with disturbed sleep
• Linden flowers (Tilia cordata): antispasmodic, mild diuretic, gentle bitter, especially with dyspepsia

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Baptesia for patients who can only swallow liquids and gag on the smallest amount of solids; especially with a red inflamed throat that is relatively pain free.
• Baryta carbonica for huge tonsils that make it difficult to swallow even liquids; especially with shyness
• Carbo vegatabilis for bloating and indigestion that is worse from lying down; especially with flatulence and fatigue
• Ignatia imara for "lump in the throat," back spasms, spasmodic cough; especially when symptoms appear after grieving
• Lachesis for difficulty swallowing, intolerance to touch around the throat, and tight clothes

Discuss etiology and prognosis with patients, including possible need for repeat dilatations. Dysphagia should not require limits on patients' activities. Depending on the degree of obstruction, diet may have to be restricted.

Counsel patients (and/or caregivers) to do the following:

• Avoid exacerbating drugs
• Chew thoroughly
• Avoid extremely hot or cold foods
• Do not drink alcohol in excess
• Correct poorly fitting dentures
• Observe infants/children carefully when eating

• Aspiration
• Esophageal "asthma"
• Pneumonia
• Barrett's syndrome; esophageal cancer

Prognosis varies from good for relatively uncomplicated dysphagia (e.g., peptic strictures) to poor for dysphagia with cancer etiologies. Speech therapy may be appropriate for patients who need to learn swallowing techniques.

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