How do you diagnose dysphagia

What are the symptoms? If you have dysphagia, you may: Have problems getting food or liquids to go down on the first try. Gag, choke, or cough when you swallow. Have food or liquids come back up through your throat, mouth, or nose after you swallow. Feel like foods or liquids are stuck in some part of your throat or chest. Have pain when you swallow. Have pain or pressure in your chest or have heartburn. Lose weight because you are not getting enough food or liquid.

How is dysphagia diagnosed? Your doctor may then refer you to one of the following specialists: An otolaryngologist , who treats ear, nose, and throat problems A gastroenterologist , who treats problems of the digestive system A neurologist , who treats problems of the brain, spinal cord, and nervous system A speech-language pathologist , who evaluates and treats swallowing problems To help find the cause of your dysphagia, you may need one or more tests, including: X-rays.

These provide pictures of your neck or chest. A barium swallow. This is an X-ray of the throat and esophagus. Before the X-ray, you will drink a chalky liquid called barium. Barium coats the inside of your esophagus so that it shows up better on an X-ray.

This test uses a type of barium swallow that allows your swallowing to be videotaped. This test looks at the back of your throat, using either a mirror or a fiber-optic scope. Esophagoscopy or upper gastrointestinal endoscopy. During these tests, a thin, flexible instrument called a scope is placed in your mouth and down your throat to look at your esophagus and perhaps your stomach and upper intestines. Sometimes a small piece of tissue is removed for a biopsy. A biopsy is a test that checks for inflammation or cancer cells.

During this test, a small tube is placed down your esophagus. The tube is attached to a computer that measures the pressure in your esophagus as you swallow. How is it treated? Your treatment will depend on what is causing your dysphagia. Treatment for dysphagia includes: Exercises for your swallowing muscles. If you have a problem with your brain, nerves, or muscles, you may need to do exercises to train your muscles to work together to help you swallow.

You may also need to learn how to position your body or how to put food in your mouth to be able to swallow better. Changing the foods you eat. Your doctor may tell you to eat certain foods and liquids to make swallowing easier. In this treatment, a device is placed down your esophagus to carefully expand any narrow areas of your esophagus. You may need to have the treatment more than once. In some cases, a long, thin scope can be used to remove an object that is stuck in your esophagus.

If you have something blocking your esophagus such as a tumor or diverticula , you may need surgery to remove it. Surgery is also sometimes used in people who have a problem that affects the lower esophageal muscle achalasia.

If you have dysphagia related to GERD, heartburn, or esophagitis, prescription medicines may help prevent stomach acid from entering your esophagus.

Examination of the teeth can reveal signs of inflammation or other structural disorders. Observing the patient swallowing a variety of liquids and solids can be helpful.

The patient should demonstrate enough neuromuscular control to chew food, mix it into a bolus with saliva and propel it to the posterior pharynx without choking or coughing. Elevation of the larynx during the swallowing reflex protects the airway and opens the upper esophageal sphincter. Normal laryngeal ascent can be palpated by placing the index finger above the patient's thyroid cartilage when the patient swallows. The cartilage should move cephalad against the physician's finger.

Thyroid masses and lymphadenopathy that cause obstructive dysphagia can be palpated on examination of the neck. A widened anteroposterior chest diameter and distant breath sounds are signs of chronic obstructive pulmonary disease, which could be caused by long-term aspiration.

The patient's abdomen should be examined for masses and organomegaly. The presence of occult blood in the stool may be a sign of neoplasms or esophagitis. Initial laboratory evaluations should be limited to specific studies based on the differential diagnosis generated after the completion of a history and physical examination. A complete blood count screens for infectious or inflammatory conditions. Thyroid function studies may detect hypo- or hyperthyroid-associated causes of dysphagia e.

Other studies should be based on specific clinical conditions. Although a patient history and physical examination identify the etiology of dysphagia in most patients, further testing may be indicated to confirm the diagnosis or to establish the patient's risk of aspiration Figure 3 14 and Table 4. Subspecialists in radiology or gastroenterology will most often conduct these tests. Some centers have multidisciplinary dysphagia teams available to offer comprehensive diagnostic evaluations and therapeutic interventions.

Evaluation, diagnosis, and treatment. Prim Care ;— Nasopharyngoscopy is particularly useful in evaluating patients with oropharyngeal dysphagias. This procedure quickly identifies structural masses and lesions, and assesses laryngeal sensitivity to contact. Overuse of topical anesthetics can anesthetize the pharynx and confuse the interpretation. Under direct observation from the level of the soft palate, the physician assesses oral containment of a colored fluid bolus in the mouth and observes pooling of fluids around the vallecula or clearing of the fluid from the oropharynx into the esophagus.

Patients who show aspiration without cough are at high risk of pulmonary complications. A barium study esophagram is often the first step in evaluating patients with dysphagia, especially if an obstructive lesion is suspected. It identifies intrinsic and extrinsic structural lesions but lacks precision in identifying the nature of obstructive lesions.

A barium study assesses motility better than endoscopy and is relatively inexpensive with few complications; however, it can be difficult to perform in sick or uncooperative patients. Double-contrast studies provide better visualization of esophageal mucosa. Barium marshmallows or pills localize obstructive lesions in the mouth or esophagus. Fluoroscopy can identify abnormalities in the mouth and oropharynx and, if observed closely, can provide some detail about function, detecting reflux and abnormal peristalsis.

Gastroesophageal endoscopy provides the best assessment of the esophageal mucosa. In patients with acute onset of dysphagia while eating, gastroesophageal endoscopy can directly remove an impacted food bolus and dilate strictures.

Endoscopy has the added benefit of detecting infection and erosions, and providing biopsy capability. While endoscopy does not assess motor function or subtle strictures as well as barium studies 15 its sensitivity for detecting Schatzki's rings is only 58 percent, compared with 95 percent for barium study , a consensus panel making final diagnoses in patients with dysphagia found that for all dysphagia diagnoses, gastroesophageal endoscopy is more sensitive 92 percent versus 54 percent and more specific percent versus 91 percent than double-contrast upper gastrointestinal radiography.

Patients at risk for silent aspiration e. Compared with upper gastrointestinal radiography, videoradiographic studies are better in identifying patients with mild strictures and extrinsic compressions e. Manometry assesses motor function of the esophagus and is indicated if no abnormality is identified by barium study or gastroesophageal endoscopy.

Manometry detects definitive abnormalities in only 25 percent of patients with nonobstructive lesions.

Its use in disorders of the oropharyngeal upper esophageal sphincter is not particularly effective, because patients do not tolerate the procedure well. Despite several drawbacks, esophageal pH monitoring remains the gold standard for diagnosing patients with suspected reflux disease. These levels are compared with the patient's record of symptoms over a hour period to determine if acid reflux contributes to the symptoms.

Combined recordings of esophageal pH levels and intraluminal esophageal pressure may aid in diagnosing patients with reflux-induced esophageal spasm. Plain radiographic films of the chest or neck offer limited information unless structural abnormalities are noted.

Computed tomography and magnetic resonance imaging scans provide excellent definition of structural abnormalities, particularly when used to evaluate patients with suspected central nervous system causes of dysphagia.

Ultrasonography of the pharynx and tongue offers no benefit compared with videofluorography, but ultrasonography may aid in the evaluation of submucosal and extramural lesions of the esophagus. Radionuclide studies may be used to evaluate transit function through the esophagus.

Family physicians can reduce the symptoms and risks of complications by early and aggressive evaluation and management of stroke patients. Physicians should recommend that all patients, especially the elderly, take their medications with a full glass of water while in an upright position well before bedtime. Patient referral is warranted when the cause of dysphagia is unclear, when there is evidence of aspiration or if further diagnostic or therapeutic expertise is necessary.

Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Michael R. Spieker, M. Reprints are not available from the author. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Navy Department or the Department of Defense.

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Contact afpserv aafp. Want to use this article elsewhere? A provider will slide an endoscope a tube with a light and camera into your nose and to the back of your throat. The endoscope allows your provider to watch food travel down your throat as you swallow. Upper Endoscopy You will lie on your side on an exam table. An IV intravenous line will be placed in your arm or hand.

Medicine to relax you will be injected into the IV. Your provider may spray a numbing medicine on the back of your throat.

Once the relaxing and numbing medicines have taken effect, your provider will insert an endoscope into your mouth and throat. The endoscope will take pictures of your esophagus, stomach, and part of your small intestine. Your provider may take a biopsy removal of a small sample of tissue to examine after the procedure. You will be given different foods and liquids that are covered with barium.

Barium is a substance that makes parts of your body show up more clearly on an x-ray While you swallow, a special x-ray called fluoroscopy will track the barium-coated food in real time as it moves through your mouth, throat, and esophagus. Will I need to do anything to prepare for the test?

Are there any risks to the tests? What do the results mean? Your results may show you have one of the following types of disorders: Oral cavity dysphagia , a disorder of the mouth. Conditions include: Weakness after a stroke Muscular or nerve problem Oropharyngeal dysphagia , a disorder of the throat. Conditions include: Certain types of cancer Neurological diseases such as multiple sclerosis or Parkinson's disease Pharyngoesophageal diverticulum, a small pouch that forms and collects food particles in your throat Esophageal dysphagia , a disorder of the esophagus.

Conditions include: Esophageal stricture narrowing of the esophagus Tumor of the esophagus GERD gastroesophageal reflux disease , a condition in which contents of the stomach leak backward into the esophagus A bedside swallow screen or other type of dysphagia screening tool will only show if you are at risk for one of the above disorders.

If you have questions about your results, talk to your health care provider. Is there anything else I need to know about dysphagia tests? If you are having trouble swallowing, your health care provider may refer you to one of the following specialists: Speech and language pathologist , a health care provider that specializes in diagnosing and treating speech, language, and communication disorders An otolaryngologist , a doctor who specializes in diagnosing and treating disorders of the ear, nose, and throat Gastroenterologist , a doctor who specializes in diagnosing and treating disorders of the digestive system Neurologist , a doctor who specializes in diagnosing and treating disorders of the brain, spinal cord, and nervous system.

Adult Dysphagia [cited Jun 19]; [about 4 screens]. Bloomfield CT : Healthwise; c— Difficulty Swallowing Dysphagia ; [cited May 12]; [about 4 screens].

Cleveland OH : Cleveland Clinic; c Difficulty Swallowing; [cited May 12]; [about 3 screens]. Dysphagia; [updated Aug 28; cited May 12]; [about 3 screens]. Mayo Foundation for Medical Education and Research; c— Dysphagia: Diagnosis and treatment; Oct 17 [cited May 12]; [about 4 screens].