Focus on Diagnosis: Dysphagia

Abstract

1. Ethan A. Mezoff, MD 1. Fellow in Pediatric Gastroenterology, Cincinnati Children’s Hospital, Cincinnati, OH. Dysphagia, or difficulty with swallowing, may present alone or with accompanying signs and symptoms. The evaluation of dysphagia is guided by an accurate and thorough history, taken in consideration of the vast differential diagnosis. A brief review of the physiology of swallowing is followed by a differential diagnosis and historical points that should direct the diagnostic evaluation. Finally, a review of diagnostic and treatment options is presented. Swallowing prepares and transfers a bolus of consumed or secreted substance from the mouth to the stomach. Initially, the pooling of oral secretions forms a bolus, with or without masticated food. This bolus is then transferred to the upper esophagus during the oropharyngeal phase of swallowing. During this phase, the epiglottis covers the larynx to prevent aspiration of the bolus. Additionally, the soft palate is elevated against the nasopharynx to prevent nasal regurgitation of the bolus. Transfer of the bolus to the stomach then occurs through peristaltic muscle contractions of the circular and longitudinal smooth muscles of the esophagus and relaxation of the lower esophageal sphincter. The developmental milestone of swallowing typically is reached at 34 weeks gestational age in premature infants. It is best to separate oropharyngeal from esophageal causes when considering the differential diagnosis of dysphagia. Oropharyngeal causes, in general, are grouped as neuromuscular, infectious/inflammatory, or structural (Table 1). Esophageal causes are divided into …