Comparison of Esophageal Motility in Patients with Solid Dysphagia and Mixed Dysphagia

It is unclear whether there is any difference in esophageal motor abnormalities between patients complaining of dysphagia for solids or both solids and liquids. The aim of this study was to determine any difference in the manometric findings between patients with dysphagia for solids and those with mixed dysphagia. Manometric tracings were performed in 200 consecutive patients (66M, 134F; mean age = 51 years) with nonobstructive dysphagia. Ambulatory pH studies were performed in all patients. Subjects were divided into two groups: patients with solid dysphagia (n = 94, 33M, 61 F; mean age = 51 years) and those with mixed dysphagia (n = 106, 33M, 73F; mean age = 51 years). A normal motility study was the most frequent finding. Achalasia occurred more frequently in patients with mixed dysphagia than in those with solid dysphagia (12% vs. 3%, p < 0.01). Gastroesophageal reflux disease (GERD) was observed in 59% of patients with solid dysphagia compared with 29% of patients with mixed dysphagia (p < 0.02). The most common esophageal motility abnormality is nonspecific esophageal motility disorders. This study has shown that abnormal esophageal motility occurs slightly more in mixed dysphagia than solid dysphagia. The clinical utility of a symptomatic differentiation of patients with solid or mixed dyphagia appears to be limited.     

Esophageal Adenocarcinoma: Pseudo-Nutcracker Esophagus

Pseudoachalasia due to adenocarcinoma is well known. We report a case of nutcracker esophagus in the setting of outflow obstruction from esophageal adenocarcinoma. Endoscopy is warranted to exclude similar lesions in patients with “pseudo-nutcracker esophagus”.

Dysphagia Associated with Risperidone Therapy

Dysphagia is occasionally reported in patients taking neuroleptic agents, although the newer, atypical neuroleptics are generally believed to be associated with fewer neurologic side effects. We report a 76-year-old man who developed radiographically confirmed dysphagia when treated with risperidone; the dysphagia resolved when risperidone was withdrawn. Clinicians should be aware of the potential for this dangerous but highly reversible problem.     

Isolated Proximal Esophageal Injury from Blunt Trauma: Endoscopic Stricture Dilatation

Blunt neck trauma can cause isolated esophageal injuries that may be difficult to recognize. A high index of suspicion is necessary for optimal identification and management of this condition. We report a case of blunt esophageal trauma resulting from a motor vehicle accident that was initially unrecognized until the patient developed a tight stricture of the cervical esophagus. This was successfully dilated endoscopically. Aerodigestive trauma resulting from neck injuries is reviewed with emphasis on the pathophysiology of esophageal trauma.     

Dysphagia Referrals to a District General Hospital Gastroenterology Unit: Hard to Swallow

The aim of our study was to audit dysphagia referrals received by a specialist gastroenterology unit during an entire year. We used a prospective audit carried out over a 12- month period at the District General Hospital gastroenterology unit. The audit included 396 consecutive patients who were referred with swallowing difficulties. We found that 60 referrals (15.2%) were inaccurate and the patients had no swallowing problem. Of the 336 patients with genuine dysphagia, only 29 (8.6%) were new cancer cases. The large majority of subjects had benign disease mostly related to acid reflux. Weight loss was significantly associated with malignancy but also occurred in one third of patients with reflux alone. The temporal pattern of dysphagia was not significantly predictive of cancer. All the cancer patients were above the age of 50 years. Although patients were in general assessed rapidly after hospital referral, the productivity, in terms of early tumor diagnosis, was extremely low. We conclude that there is a substantial rate of inaccurate referrals of dysphagia patients. Most true cases of swallowing difficulty relate to benign disease. Even the devotion of considerable resources to the early diagnosis of esophago gastric malignancy in an attempt to conform with best practice guidelines results in a very low success rate in terms of the detection of potentially curable tumors.     

The Nutcracker Esophagus: A Late Diagnostic Yield Notwithstanding Chest Pain and Dysphagia

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23–78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21–67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 ± 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.     

Neuroleptic-Induced Dysphagia: Case Report and Literature Review

Neuroleptic medication may cause extrapyramidal symptoms (EPS) that can affect swallowing as well. This report describes a case of drug-induced dysphagia in a 53-year-old man receiving haloperidol for treatment of schizophrenia. The diagnosis was established by fiberoptic endoscopic evaluation of swallowing. After changing medication to fluphenazin, dysphagic symptoms resolved. The literature on EPS-related dysphagia, its demographic features, typical symptoms, diagnostic modalities, clinical course, and treatment options is reviewed. Rainer Dziewas and Tobias Warnecke contributed equally to this work.     

Retrospective Analysis of Esophageal Food Impaction: Differences in Etiology by Age and Gender

Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18–100). The most common etiologies of EFI were Schatzki's ring (n=18), peptic stricture (n=18), EE (n=9), esophagitis (n=9), and no underlying diagnosis (n=20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age=44) and women (median age=71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.     

Dysphagia and dementia in subjects with Parkinson's disease

This study reviewed the medical records of 19 patients with a diagnosis of Parkinson's disease listed on the death certificate who died between June 1985 and July 1990. The presence or absence of dementia separated the patients into two groups. The study examined the age at time of death, number and type of secondary diagnoses, frequency of dysphagia diagnosis, and therapeutic dietary differences. The presence of dementia did not influence the age at time of death. Dysphagia was a common diagnosis for each group. Differences in treatment of dysphagia were found to be dependent on the presence or absence of dementia.     

Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making

The purpose of this study was to determine the nature of swallowing evaluation practices in western Washington, specifically in terms of (a) components of the clinical examination most commonly used, (b) consistency of clinical examination practices across clinicians, and (c) consistency of clinical decision-making (instrumental vs. noninstrumental) given specific patient scenarios. A 21-question survey was sent to 150 speech-language pathologists who provide services to dysphagia patients. Of the 72 (48%) surveys that were returned, 64 provided the data for the study. The results revealed that clinicians who responded to the survey differ somewhat regarding which components they include in a clinical examination of swallowing. There was a high degree of consistency for 11 of the 19 components. Inconsistency across clinicians was revealed in four areas: assessment of sensory function, assessment of the gag reflex, cervical auscultation, and assessment of trial swallows using compensatory techniques. Clinicians agreed in their recommendations on two of the six clinical case scenarios. In general, participating clinicians varied widely in their clinical decision-making. These findings are compared with other studies where variability in clinical practice has raised concerns. This work was performed at Western Washington University. This work was funded in part by a grant from the Bureau of Faculty Research, Western Washington University.     

Prevalence of Dysphagia Among Community-Dwelling Elderly Individuals as Estimated Using a Questionnaire for Dysphagia Screening

The objective of this cross-sectional study was to determine the prevalence of dysphagia among elderly persons living at home in a community using a questionnaire for dysphagia screening. As the reliability of the questionnaire had not yet been confirmed in an epidemiological study, it was also verified. The relationship between dysphagia and the level of daily living competence was also clarified. The subjects consisted of 1313 elderly persons 65 years and older (575 males and 738 females) living at home in a community. The questionnaire included questions concerning the individuals past history of stroke, and questions for dysphagia screening, competence scoring, and perceived ill health. The reliability of the questionnaire was confirmed after calculating the Cronbachs alpha coefficient to be 0.83. The results of a factor analysis showed that the cumulative contribution rate was 61.8%. The prevalence rate of dysphagia was 13.8%. After matching for age and sex, there were significant differences in the competence scores, history of stroke, and perceived ill health status observed between the group with dysphagia and the group without dysphagia.     

Dysphagia and Hoarseness Associated with Painless Aortic Dissection: A Rare Case of Cardiovocal Syndrome

Cardiovocal syndrome (Ortner’s syndrome) is characterized by left recurrent laryngeal nerve palsy due to cardiovascular disease, but in rare cases it can also be caused by aortic dissection. An 81-year-old man with hypertension was admitted to the hospital with aspiration pneumonia. He had been developing progressive dysphagia and hoarseness for several months before admission. A videofluoroscopic swallowing study showed supraglottic penetration with barium paste and liquid. Laryngoscopy and electromyography revealed left vocal cord palsy caused by left recurrent laryngeal neuropathy, and a contrast-enhanced chest CT revealed dissection of the aortic arch.No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.     

A Qualitative Study of the Problems Surrounding Medicine Administration to Patients with Dysphagia

Swallowing dysfunction in the elderly is common and affects not only nutrition but also the ingestion of medicines. This qualitative study used a focus group to collect data from ten healthcare professionals who are involved in the care of people with swallowing difficulties. The group discussed their experiences of the problems associated with and solutions to the administration of medicines to patients with dysphagia. The focus group was audiotaped, and the data analysed using Colaizzi’s technique. Six themes were identified, three main ones: (1) the wide spectrum of dysphagia; (2) medicine formulation, which affects how drugs can be administered; (3) problems with data flow, i.e., the correct information being with the right person at the right time and in the right place; and three minor ones which arose from the major themes: (4) the primary function of swallowing is nutrition rather than taking medication; (5) cost of medicines; and (6) therapeutic dilemmas. The study concludes that improvements in interprofessional communication are needed to improve medicine administration to dysphagic patients.

Dysphagia diagnostics and Donner: Experiences in the decade of change

Martin Donner's influence in the area of dysphagia diagnostics has spanned several decades and has provided an impetus for the evolution of advanced dysphagia diagnostics. This article presents an historical perspective of the development of ultrasound imaging and the variety of other imaging procedures to evaluate swallowing. The future of image processing for dysphagia is firmly set.     

Dysphagia in cerebral palsy: A comparative study of the exeter dysphagia assesment technique and a multidisciplinary assessment

Eighteen children with cerebral palsy in a special school, most of whom had feeding difficulties, were studied to compare the diagnostic value of the Exeter Dysphagia Assessment Technique (EDAT) with an exhaustive clinical assessment undertaken by a multidisciplinary team experienced in the diagnosis and treatment of dysphagia of neurological origin. Four feeding skills were assessed by each method independently, viz. anticipation, intraoral sensory perception, oral-motor efficiency, and pharyngeal triggering. Comparison of the two sets of results showed agreement in at least 78% of the assessed skills. The possible reasons for the few discrepancies are discussed. The noninvasive EDAT equipment was easy to use with the children, who had a range of type and severity of cerebral palsy. The test was undertaken in their familiar surroundings and took 15 to 20 min per child. Interpretation of the results showed that EDAT provided a rapid, reliable diagnostic aid which assisted in the assessment of the degree of feeding impairment within each of the four feeding skills tested. The authors are very grateful for the financial support for this project which was provided partially by Action Research and partially by the Northcott Devon Medical Foundation     

Eosinophilic esophagitis in patients with esophageal atresia and chronic dysphagia

Esophageal atresia (EA) is defined as a discontinuity of the lumen of the esophagus repaired soon after birth. Dysphagia is a common symptom in these patients, usually related to stricture, dysmotility or peptic esophagitis. We present 4 cases of patients with EA who complained of dysphagia and the diagnosis of Eosinophilic esophagitis (EoE) was made, ages ranging from 9 to 16 years. Although our patients were on acid suppression years after their EA repair, they presented with acute worsening of dysphagia. Esophogastroduodenoscopy and/or barium swallow did not show stricture and biopsies revealed elevated eosinophil counts consistent with EoE. Two of 4 patients improved symptomatically with the topical steroids. It is important to note that all our patients have asthma and 3 out of 4 have tested positive for food allergies. One of our patients developed recurrent anastomotic strictures that improved with the treatment of the EoE. A previous case report linked the recurrence of esophageal strictures in patients with EA repair with EoE. Once the EoE was treated the strictures resolved. On the other hand, based on our observation, EoE could be present in patients without recurrent anastomotic strictures. There appears to be a spectrum in the disease process. We are suggesting that EoE is a frequent concomitant problem in patients with history of congenital esophageal deformities, and for this reason any of these patients with refractory reflux symptoms or dysphagia (with or without anastomotic stricture) may benefit from an endoscopic evaluation with biopsies to rule out EoE.     

Long-term Botulinum Toxin Treatment for Dysphagia Due to Large Epiphrenic Diverticulum in Elderly Patients: A Report of Two Cases

Symptomatic esophageal epiphrenic diverticula are usually repaired with diverticulectomy and esophagomyotomy with substantial morbidity and mortality rates, especially in elderly patients. We describe the cases of two elderly patients who had dysphagia caused by large epiphrenic diverticula. Due to severe comorbid diseases, both patients were unable to withstand surgical intervention; botulinum toxin solution was injected endoscopically at multiple sites in the region of the lower esophageal sphincter and esophageal wall near the diverticulum. Symptoms improved immediately and the beneficial effect of botulinum toxin remained for 5–6 months. During the long-term follow-up, the patients developed symptomatic relapses treated by subsequent botulinum toxin solution reinjections resulting in longer-lasting symptom relief.

Anterior Cervical Osteophytes Causing Dysphagia and Dyspnea: An Uncommon Entity Revisited

Large anterior cervical osteophytes can occur in degeneration of the cervical spine or in diffuse idiopathic skeletal hyperostosis (DISH). We present the case of an 83-year-old patient with progressive dysphagia and acute dyspnea, necessitating emergency tracheotomy. Voluminous anterior cervical osteophytes extending from C3 to C7 and narrowing the pharyngoesophageal segment by external compression and bilateral vocal fold immobility were diagnosed radiologically and by fiberoptic laryngoscopy. Surgical removal of all osteophytes led to the resolution of symptoms. Dyspnea with or without dysphagia caused by hypertrophic anterior cervical osteophytes is an uncommon entity. The exhaustive diagnostic workup proposed in the literature could be simplified by using fiberoptic laryngoscopy and dynamic videofluoroscopy. The causes, treatment, and outcome are discussed.