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++

Probability diagnosis

++

Functional (e.g. ‘express’ swallowing, psychogenic)

++

Tablet-induced irritation

++

Pharyngotonsillitis

++

GORD/reflux oesophagitis

++

Serious disorders not to be missed

++

Neoplasia/cancer:

++

  • cancer of the pharynx, oesophagus (esp.) stomach

  • extrinsic tumour

++

AIDS (opportunistic oesophageal infection)

++

Stricture, usually benign peptic stricture

++

Scleroderma

++

Neurological causes:

++

  • pseudobulbar palsy

  • multiple sclerosis

  • motor neurone disease (amyotrophic sclerosis)

  • Parkinson disease

++

Pitfalls (often missed)

++

Foreign body

++

Drugs (e.g. phenothiazines)

++

Subacute thyroiditis

++

Extrinsic lesions (e.g. lymph nodes, goitre)

++

Upper oesophageal web (e.g. Plummer–Vinson syndrome)

++

Eosinophilic oesophagitis

++

Radiotherapy

++

Achalasia

++

Upper oesophageal spasm (mimics angina)

++

Rarities (some):

++

  • Sjögren syndrome

  • aortic aneurysm

  • aberrant right subclavian artery

  • lead poisoning

  • cervical osteoarthritis (large osteophytes)

  • other neurological causes

  • other mechanical causes

++

Masquerades checklist

++

Depression

++

Drugs

++

Thyroid disorder

++

Is the patient trying to tell me something?

++

Yes. Could be functional ?globus hystericus.

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Key history

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Analyse the nature of the symptom: difficulty in swallowing. Its origin is either oropharyngeal or oesophageal. A careful history includes a drug history and psychosocial factors.

++

Key examination

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  • Focus on the patient’s general features, mouth, oropharynx, larynx, neck (esp. lymphadenopathy and thyroid) and any abnormal neurological features especially cranial nerve function and muscle weakness disorders

++

Key investigations

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Consider:

++

  • FBE

  • oesophageal manometry study (manometry)

  • endoscopy ± barium swallow

  • CXR.

++

The primary investigation in suspected pharyngeal dysphagia is a video barium swallow, while endoscopy is generally the first investigation in cases of suspected oesophageal dysphagia.

++

Diagnostic tips

++

  • Dysphagia must not be confused with globus hystericus, which is the sensation of the ‘constant lump in the throat’ although there is no actual difficulty swallowing food.

  • Mechanical dysphagia represents cancer until proved otherwise.

  • Be careful of a change in symptoms in the presence of longstanding reflux (consider stricture or cancer).

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