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Probability diagnosis

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

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Tablet-induced irritation

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Pharyngotonsillitis

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GORD/reflux oesophagitis

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Serious disorders not to be missed

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Neoplasia/cancer:

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

  • extrinsic tumour

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AIDS (opportunistic oesophageal infection)

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Stricture, usually benign peptic stricture

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Scleroderma

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Neurological causes:

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  • pseudobulbar palsy

  • multiple sclerosis

  • motor neurone disease (amyotrophic sclerosis)

  • Parkinson disease

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Pitfalls (often missed)

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Foreign body

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Drugs (e.g. phenothiazines)

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Subacute thyroiditis

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

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

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Eosinophilic oesophagitis

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Radiotherapy

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Achalasia

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Upper oesophageal spasm (mimics angina)

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Rarities (some):

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  • Sjögren syndrome

  • aortic aneurysm

  • aberrant right subclavian artery

  • lead poisoning

  • cervical osteoarthritis (large osteophytes)

  • other neurological causes

  • other mechanical causes

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Masquerades checklist

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Depression

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Drugs

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Thyroid disorder

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Is the patient trying to tell me something?

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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.

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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

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Key investigations

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Consider:

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  • FBE

  • oesophageal manometry study (manometry)

  • endoscopy ± barium swallow

  • CXR.

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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.

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Diagnostic tips

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  • 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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