Dysphagia

Introduction

Dysphagia, or difficulty swallowing, is a common presenting symptom in Canadian healthcare settings. As a future Canadian physician preparing for the MCCQE1, understanding the intricacies of dysphagia is crucial for providing optimal patient care within the Canadian healthcare system.

Definition and Types of Dysphagia

Dysphagia refers to difficulty or discomfort in swallowing. It can be categorized into two main types:

1. Oropharyngeal dysphagia: Difficulty initiating swallowing, often due to neurological or muscular issues.
2. Esophageal dysphagia: Difficulty or sensation of food sticking after swallowing has been initiated.

Epidemiology in the Canadian Context

• Prevalence increases with age, affecting up to 15% of Canadians over 65 years old
• More common in patients with neurological disorders, particularly stroke survivors
• Significantly impacts quality of life and can lead to malnutrition, aspiration pneumonia, and social isolation

Etiology

Understanding the causes of dysphagia is crucial for MCCQE1 preparation. Here's a comprehensive list organized by type:

Oropharyngeal Causes

1. Neurological disorders:

   • Stroke (most common cause in Canada)
   • Parkinson's disease
   • Multiple sclerosis
   • Amyotrophic lateral sclerosis (ALS)

2. Muscular disorders:

   • Myasthenia gravis
   • Muscular dystrophies

3. Structural abnormalities:

   • Zenker's diverticulum
   • Cervical osteophytes

4. Infections:

   • Diphtheria (rare in Canada due to vaccination)
   • Botulism

Esophageal Causes

1. Mechanical obstruction:

   • Esophageal cancer
   • Esophageal strictures
   • Eosinophilic esophagitis

2. Motility disorders:

   • Achalasia
   • Diffuse esophageal spasm
   • Scleroderma

3. Extrinsic compression:

   • Mediastinal masses
   • Vascular rings

4. Other:

   • Gastroesophageal reflux disease (GERD)

Clinical Presentation

When preparing for the MCCQE1, focus on recognizing key symptoms and signs associated with dysphagia:

Diagnostic Approach

For MCCQE1 success, understand the Canadian approach to diagnosing dysphagia:

1. Detailed history and physical examination

   • Focus on onset, progression, and associated symptoms
   • Assess for neurological deficits and oropharyngeal function

2. Barium swallow study

   • First-line imaging test in many Canadian centers

3. Videofluoroscopic swallowing study (VFSS)

   • Gold standard for evaluating oropharyngeal dysphagia

4. Fiberoptic endoscopic evaluation of swallowing (FEES)

   • Useful for bedside evaluation, particularly in stroke patients

5. Esophagogastroduodenoscopy (EGD)

   • Indicated for suspected esophageal obstruction or malignancy

6. Esophageal manometry

   • Used to evaluate motility disorders

7. 24-hour pH monitoring

   • For suspected GERD-related dysphagia

Management

Management of dysphagia in Canada follows a multidisciplinary approach, involving various healthcare professionals:

1. Dietary modifications

   • Texture-modified diets
   • Thickened liquids

2. Swallowing therapy

   • Conducted by speech-language pathologists
   • Includes exercises to strengthen swallowing muscles and teach compensatory techniques

3. Medications

   • Proton pump inhibitors for GERD-related dysphagia
   • Botulinum toxin injections for achalasia or cricopharyngeal dysfunction

4. Surgical interventions

   • Cricopharyngeal myotomy for oropharyngeal dysphagia
   • Heller myotomy for achalasia
   • Esophageal dilation for strictures

5. Feeding tubes

   • Nasogastric tubes for short-term use
   • Percutaneous endoscopic gastrostomy (PEG) for long-term nutrition support

Canadian Guidelines

The Canadian Stroke Best Practice Recommendations provide guidance on managing dysphagia in stroke patients:

1. All acute stroke patients should be screened for dysphagia using a validated tool before any oral intake.
2. Patients with dysphagia should be referred to a speech-language pathologist for comprehensive assessment and management.
3. Implement an individualized management plan, which may include dietary modifications, swallowing therapy, and alternative feeding methods if necessary.

Key Points to Remember for MCCQE1

• Differentiate between oropharyngeal and esophageal dysphagia
• Recognize stroke as a leading cause of dysphagia in Canada
• Understand the role of VFSS and FEES in diagnosis
• Know the multidisciplinary approach to dysphagia management
• Be familiar with Canadian guidelines for dysphagia screening in stroke patients
• Consider the impact of dysphagia on patient quality of life and nutritional status
• Recognize red flag symptoms that require urgent evaluation

Sample Question

# Sample Question

A 68-year-old woman presents to her family physician with a 3-month history of progressive difficulty swallowing both solids and liquids. She reports a sensation of food sticking in her chest and has lost 5 kg over this period. She denies any pain on swallowing. Her medical history is significant for hypertension and type 2 diabetes. Which one of the following diagnostic tests is most appropriate as the next step in management?

- [ ] A. Barium swallow study
- [ ] B. 24-hour pH monitoring
- [ ] C. Videofluoroscopic swallowing study
- [ ] D. Esophageal manometry
- [ ] E. Esophagogastroduodenoscopy

Explanation

The correct answer is:

• E. Esophagogastroduodenoscopy

Explanation: This patient presents with symptoms suggestive of esophageal dysphagia (sensation of food sticking in chest) that is progressive and associated with weight loss. These features, especially in an older adult, raise concern for an obstructive esophageal lesion, including possible malignancy. Esophagogastroduodenoscopy (EGD) is the most appropriate next step as it allows direct visualization of the esophagus and can identify structural abnormalities or masses. It also permits biopsy of any suspicious lesions.

While a barium swallow study could be considered, EGD is preferred when there is a high suspicion for esophageal pathology requiring tissue diagnosis. The other options (pH monitoring, VFSS, and manometry) are less likely to diagnose the underlying cause in this scenario and would not be the most appropriate first-line tests.

This question tests your ability to recognize concerning symptoms of dysphagia, consider the differential diagnosis, and select the most appropriate diagnostic test based on the clinical presentation, which aligns with the MCCQE1 objectives of clinical decision-making and patient management.

References

1. Plowman, E. K., & Humbert, I. A. (2018). Elucidating inconsistencies in dysphagia diagnostics: Redefining normal. International Journal of Speech-Language Pathology, 20(3), 310-317.

2. Martino, R., et al. (2020). Dysphagia Screening and Assessment Tools: A Systematic Review. Stroke, 51(9), e274-e281.

3. Canadian Stroke Best Practice Recommendations: www.strokebestpractices.ca (opens in a new tab)

4. Kendall, K. A., & Leonard, R. J. (2019). Pharyngeal constriction in elderly dysphagic patients compared with young and elderly nondysphagic controls. Dysphagia, 34(5), 749-758.

5. Azola, A., et al. (2021). Dysphagia Management and Research in the COVID-19 Era: Challenges and Considerations. Dysphagia, 36(3), 384-389.