Operational Medicine 2001
Difficulty Swallowing

Difficulty swallowing is a complaint that can be very complex to arrive at a diagnosis.  However, the goal of evaluating swallowing problems should be to determine if the problem is one that needs immediate medical intervention, or if it is one that can be observed with follow up at a later time. 

The first task is to differentiate dysphagia (the sensation of difficulty swallowing) from odynophagia (pain with swallowing which can lead to difficulty swallowing.) This difference should be easily obtainable by history. Odynophagia suggests an inflammatory or irritative lesion in the mouth or esophagus. Dysphagia can be caused by loss of coordinated motor function (neuromuscular problems) or by mechanical obstruction. Dysphagia due to mechanical obstruction and odynophagia most often will be the causes that require urgent care.

The history and physical exam can reveal the cause in up to 80 percent of patients. A neuromuscular problem is suggested by:

• Slow onset

• Slow progression

• Chronic course

• Equal trouble with liquids and solids

• Worsening of symptoms with cold substances

• Ability to swallow the food/liquid after repeated swallows

Mechanical obstruction is suggested by:

• More rapid onset and progression

• More difficulty with solids than liquids

• Regurgitation with swallowing

Infection or inflammatory causes are suggested by:

• Pain with swallowing

• Fevers

• Sore throat 

Note any history of gastroesophageal reflux (suggesting esophageal stricture,) use of orally inhaled steroids (which could lead to thrush,) or any immunodeficiency states (though HIV would be unlikely aboard ship.) 

On physical exam, first evaluate the patient’s fluid and nutritional status. Does this look like somebody who has been unable to eat or drink due to their complaints or do they look well nourished and hydrated? This may give clues to the chronicity and severity of the problem and help with management decisions.  

Examine the mouth with a gloved hand, noting the: 

• Teeth (any missing teeth which may be lodged in the esophagus)

• Tongue (is it swollen or not moving correctly)

• Palate (does it properly raise when the patient says “ahh,”)

• Posterior mouth for any erythema, exudates, masses, enlarged tonsils, or perhaps foreign bodies.  

Palpate the neck, which may reveal enlarged lymph nodes (infection or inflammation,) the thyroid gland (a large thyroid can cause dysphagia.)  

A thorough neurological exam is essential, looking for fatigability (myasthenia gravis,) strength, reflexes, cranial nerves, and abnormal gag reflex.Observation of the patient while swallowing may be helpful.

The only laboratory evaluation that may be helpful (though not always accessible) would be an anteroposterior and lateral neck X-ray.  This may reveal foreign bodies, retropharyngeal abscesses (a complication of throat infections,) masses, epiglottitis, or large osteophytes on the cervical spine that may be compressing the esophagus.  No other tests would be helpful in the acute work up of this complaint, though a chest X-ray may show intrathoracic masses.  These studies should be dictated by findings on history and physical exam.

At this point, you should start considering some differential diagnoses and should begin to decide whether this problem needs emergent care or not.  Any problems which are progressing quickly or which may progress to cause airway compromise should be treated immediately, if possible, or evaluated for Medevac.  Problems that require immediate care include foreign bodies, peritonsillar and retropharyngeal abscesses, and epiglottitis (can proceed to airway compromise.)  Findings suggestive of neuromuscular problems or masses causing dysphagia, though medically worrisome, may not require immediate intervention.

Management begins with the A-B-C’s and evaluation of any life-threatening conditions.  Protecting the airway may be the first concern.  Some patients may be dehydrated due to decreased oral intake and may require IV rehydration.  For infectious causes (strep throat, candidal esophagitis or thrush,) appropriate medicinal agents based on the suspected pathogen (or whatever you have available) should be started.  Cases of foreign body, peritonsillar abscess or retropharyngeal abscess require prompt evaluation at a medical facility that can perform endoscopy (foreign body) or surgical drainage (abscesses.)  Other causes listed above are usually not medical emergencies and definitive diagnosis and treatment can be delayed.  Regardless of the cause, clinical judgment of a patients stability should always come first.

This section provided by LT James B. Witkowski, MC, USNR

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Operational Medicine 2001
Health Care in Military Settings

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