1. Causes of dysphagia
Definition: Dysphagia is definied as difficulty in swallowing which may affect any part of the
swallowing pathway from the mouth to stomach.
An accurate diagnosis of the cause is based on a detailed history, clinical examination which includes
indirect laryngoscopy &/ or flexible nasolaryngoscopy & special investigations.
History & examination
Special investigations
1. Blood tests:
Full blood count to exclude anaemia.
ESR or C-reactive protein may be raised in malignancy or chronic inflammation.
Liver & kidney function tests with serum calcium should be acquired when nutrition is
impaired or metastasis are suspected.
Thyroid functions tests are indicated dysphagia is caused by a goitre or thyroid malignancy.
Creatine kinase levels may be elevated in myopathies.
2.Barium swallow: In practice the test focuses on oesophagus & is poor for picking up pharyngeal
disease. It is useful for diagnosis a pharyngeal pouch, stricture, hiatus hernia,& obstructing
oesophageal lesion.
3. Chest x-ray: this should be carried out all patients with true dysphagia. Sign of aspiration & chest
infection, presence of pulmonary neoplasm & metastasis.
4.CT scanning: patient with malignancy should have a CT scanning of the neck, chest& abdomen as
those have dysphagia due to extrinsic compression.
4. MRI: is indicated whenneurological cause is suspected such as multiple sclerosis, cerebral tumour,
it is useful for lesion around the foramen magnum & brain stem. It is also used to diagnose the
vascular anomalies.
5. Direct laryngoscopy (D/L): this is performed to visualised & biopsy from pharynx, upper
oesophagus, postcricoid area,
6. Flexible endoscopic examination of upper GIT: this is performed by gastroenterologist to
visualize,assess,stage, biopsy the oesophagus in the patients with oesophagitis, barrett’s
oesophagus & tumours.
It is poor at detecting the disease of the hypopharynx because this zone is passed very rapidly&
cannot examine the pyriform fossa adequately.

2. 7. Barium videofluoroscopy swallowing study: is considered the gold standared for evaluating the
swallowing mechanism. It is a comprehensive test for all phases of swallowing particularly oral &
pharyngeal phases.
Liquid , purees & solid are used. The passage of these are observed in both lateral & anteroposterior
view. Evaluating for transit time,pooling,aspiration as well as motor function.
This is particularly useful in patients with neurological disease , after surgery or radiotherapy.
8.Manometry: this is employed to measure oesophageal pressure at rest& during swallowing to
diagnosis motility disorders.
It is helpful in patients with atypical chest pain & unexplained cause of dysphagia. Conditions with
pathognomonic manometric finding include achalasia , diffuse oesophageal spasm, nutcracker
oesophagus & scleroderma.
9.Twenty four( 24) hours ambulatory oesophageal pH monitoring:
This is regarded as most accurate method of diagnosing gastroesophageal reflex. It is useful when
standard investigations such as flexible endoscopy of upper GIT tract& barium swallow are normal in
a patient with typical symptoms or in patients with atypical symptoms such as chest pain, globus
pharyngeus, hoarseness & recurrent chest infections.
A sensor is placed 5cm above lower oesophageal sphincter, continually monitors the pH over test
period, while the patient records their symptoms, mealtimes, going to bed & getting up in a diary
card.
Normal oesophageal pH varies between 5 to 7 & gastrooesphageal reflex is present when the pH is
less than 4. The result is express as the the percentage of time, the pH is less than 4 over a 24-hour
period- the DeMeester score.
Causes of dysphagia
1.Congenital
Choanal atresia
Cleft lip & palate
Laryngomalacia
Unilateral vocal cord paralysis
Laryngeal cleft
Tracheoosphageal fistula & oesophageal atresia
Vascular ring
2.Acquired

3. 1.Traumatic
Trauma to the head neck, chest or cervical spine may disrupt the swallowing mechanism directly or
indirectly affecting the cranial nerves IX to XII nerves.
Head injuries cn produce a variety of neurological defects resulting in paralysis, or loss of
coordination of the swallowing mechanism.
2.Infections
Infections are one of the most common causes of dysphagia & are obvious when they affect the oral
cavity & orophaynx.
Acute onset of dysphagia during a coryzal-like illness suggests an infective cause for the dysphagia.
Acute pharyngitis & tonsillitis are the most common cause presenting with fever, malaise & painful
dysphagia. The initial viral infection usually predisposes to a secondary bacterial infection most
commonly ,beta-haemolytic streptococcus. Despite appropriate antibiotic therapy, tonsillitis can
progress to a peritonsillar abscess.
Glandular fever caused by the Epstein- Barr virus can also cause pharyngitis with severe painful
dysphagia & associated with cervical lymphadenopathy.
Acute supraglottitis is now rare cause of painful dysphagia in children, due to immunization with the
haemophilus influenza type B vaccine. Acute epiglottitis should be suspected in a child who becomes
rapidly unwell with fever, stridor, painful dysphagia & drooling. Supraglottitis in adults are more
protracted course,strior may not be present, & diagnosis can be confirmed by fibreptic
nasopharyngoscopy.
Oral candidiasis is diagnosed on clinical examination. Candidiasis can affect the hypopharynx &
oesophagus. Oesophagoscopy is the investigation of choice for diagnosis when a swab may be taken.
Barium swallow demonstrates a characteristic shaggy mucosal appearance that may make
endoscopy unnecessary .
Tuberculosis is a chronic infection that can cause dysphagia by either a mucosal lesion or
compression of the oesophagus by enlarged lymph node.
Abscesses of the head & neck spaces can result in significant painful dysphagia with drooling in
patients who are unwell with high fever & torticolis of the affected area. The most common in adult
are peritonsillar abscess followed by submandibular space & parapharyngeal space. Retropharyngeal
abscess are more common in children, rare in adult.
3.Inflammatory
Gastrooesophageal reflex disease is one of the most common causes of dysphagia with most
patients complaining of a tightness of the lower neck, constant throat clearance, retrosternal
discomfort & hoarseness. Only complaining of gradually increasing dysphagia when acid reflex is
associated with stricture formation. Clinical examination may show erythema &oedema of the
posterior larynx & lower pharynx. Flexible endoscopy is necessary for diagnosis. Inflammatory
change seen in the oesophagus range from mild erythema which is equivocal evidence of reflex.

4. (erythema> erosion>ulceration> stricture) may be seen. Twenty four hours ambulatory oesophageal
pH monitoring is the most accurate way to diagnosis.
In Patterson Brown-Kelly or Plummer-vincent syndrome, dysphagia mostly affects middle aged
women, associated with atrophic gastritis, iron deficiency anaemia, smooth tongue, augular
stomatitis& koilonychia. The dysphagia is due to hyperkeratinisation with web formation inthe post-cricoid
region & can be seen in Barium swallow examination. Dysphagia with hyperkeratinitization
treated with iron replacement. But web may need dilatation.
Systemic autoimmune disease associated with dysphagia. Scleroderma & CREST
syndrome(calcinosis,Raynaud’s, oesophageal involvement,sclerodactly, telangiectasis) are
progressive connective tissue disorder that may atropy & fibrosis of smooth muscle. They often
affect the lower oesophagus resulting poor peristalsis, severe GERD with stricture formation &
Barrett’s oesophagus. Diagnosis based on clinical examination & autoantibody profile
.SLE,dermatomyositis, mixed connective tissue disorder, pemphigoid, primary & secondary Sjogren’s
syndrome Rhumatoid arthritis, sarciodosis.
4.Oesophageal motility disorders(manometry)
These disorders can produce severe dysphagia in the absence of visible abnormalities, the diagnosis
being made by manometry.
Achalasia is due to failure of relaxation of the lower oesophageal sphincter with progressive
dilatation of the oesophagus. This is due to degeneration of ganglion cells of the auerbach’s plexus
inthe oesophageal wall(chagas disease due to trypanosome cruzi which destroys ganglion cells). The
patient complain progressive dysphagia to fluid then to solid and eventually regurgitate of
undigested food material. Diagnosis is made by barium swallow showing initially bird beak tapering
of the gastrooesophageal junction whic later dialatation of the oesophagus. Manometry is helpful to
early diagnosis even before the barium appearance.
Diffuse oesophageal spasm & Nutcracker oesophagus angina like chest pain. Manometry shows
nonperistaltic multipeak contraction of the high amplitude of the body of the oesophague in diffuse
spasm & in Nutcracker oesophagus,normal peristaltic waves of high amplitude in the distal
oesophagus.
5.Neoplastic (biopsy)
Both benign & malignant tumours may cause dysphagia by mechanical obstruction & also
neuromuscular invasion. Malignant & benign tumour of oral cavity, pharynx, oesophagus. Enlarged
mediastinal lymph nodes.
6.Neurological (barium videofluoroscopy)
Cerebrovascular accident or stroke is the most common neurological disorders causing dysphagia by
affecting the cortex or corticobulbar tracts(pseudobulbar palsy) or bulbar nerve nuclei (bulbar
palsy). Recovery takes place within the first week in the majority of the patients. Factors contributing
the dysphagia: 1.delayed triggering of the swallowing reflex.
2.cricopharyngeal dysfunction

5. 3.loss of pharyngeal sensation associated with the dysphagia with aspiration.
Aspiration pneumonia being a major cause of death after a stroke.
4. reduced tongue control & pharyngeal contraction & cough.
Parkinson’s disease is progressive & characterized by the triad of resting tremor, bradykinesia &
rigidity. Finding on videofluoroscopy shows impaired motility, hypopharyngeal stasis, aspiration &
poor movement of the epiglottis.
Multiple sclerosis is ademyelinating disease of the CNS. The patient may present with either
relapse& remission or a progressive syndrome. Swallowing problems tend to occur in end stage
disease. Demyelinating in a single nerve can cause of all three phases of swallowing.
Myasthenia gravis is characterized by fatiguable weakness of the striated muscle due to impaired
transmission across the neuromuscular junction.bulbar muscles weakness is the cause of the
dysphagia , weak tongue movement, food residue in the oropharynx. There may be aspiration.
Motor neuron disease (amyotrophic lateral sclerosis) is a progressive disease of the corticobulbar&
corticospinal tracts. Progressive dysphagia mainly affecting the oral& pharyngeal phase.
7.Drug-induced
Swallowing tablets with insufficient water or just before going to bed can cause oesophagitis as
oesophageal transit time is longer during sleep. Drugs with pH of less than 3 such as tetracycline,
doxycycline vitasmin C & ferrous sulphate.
Drugs side effects may be inhibitory ( anticholinergic, tricyclic antidepressant, calcium channel
blockers ).
Dysphagia by causing xerostoma antiHTN, ACEinhibitors, anticholinergic, antihistamins,antiemetics .
8.Ageing
Presbydysphagia refers to swallowing difficulties due to ageing which affects all stage of swallowing.
Key points
Oesophageal manometry can be helpful in patient with atypical chest pain & unexplained
dysphagia(motility disorder).
Twenty four hour oesophageal pH monitoring is most accurate method of diagnosing GERD.
A barium videofluoroscopy study is the gold standard for evaluating the swallowing mechanism
particularly for the oral & pharyngeal phase(neurological disorders).

6. 3.loss of pharyngeal sensation associated with the dysphagia with aspiration.
Aspiration pneumonia being a major cause of death after a stroke.
4. reduced tongue control & pharyngeal contraction & cough.
Parkinson’s disease is progressive & characterized by the triad of resting tremor, bradykinesia &
rigidity. Finding on videofluoroscopy shows impaired motility, hypopharyngeal stasis, aspiration &
poor movement of the epiglottis.
Multiple sclerosis is ademyelinating disease of the CNS. The patient may present with either
relapse& remission or a progressive syndrome. Swallowing problems tend to occur in end stage
disease. Demyelinating in a single nerve can cause of all three phases of swallowing.
Myasthenia gravis is characterized by fatiguable weakness of the striated muscle due to impaired
transmission across the neuromuscular junction.bulbar muscles weakness is the cause of the
dysphagia , weak tongue movement, food residue in the oropharynx. There may be aspiration.
Motor neuron disease (amyotrophic lateral sclerosis) is a progressive disease of the corticobulbar&
corticospinal tracts. Progressive dysphagia mainly affecting the oral& pharyngeal phase.
7.Drug-induced
Swallowing tablets with insufficient water or just before going to bed can cause oesophagitis as
oesophageal transit time is longer during sleep. Drugs with pH of less than 3 such as tetracycline,
doxycycline vitasmin C & ferrous sulphate.
Drugs side effects may be inhibitory ( anticholinergic, tricyclic antidepressant, calcium channel
blockers ).
Dysphagia by causing xerostoma antiHTN, ACEinhibitors, anticholinergic, antihistamins,antiemetics .
8.Ageing
Presbydysphagia refers to swallowing difficulties due to ageing which affects all stage of swallowing.
Key points
Oesophageal manometry can be helpful in patient with atypical chest pain & unexplained
dysphagia(motility disorder).
Twenty four hour oesophageal pH monitoring is most accurate method of diagnosing GERD.
A barium videofluoroscopy study is the gold standard for evaluating the swallowing mechanism
particularly for the oral & pharyngeal phase(neurological disorders).