Dysphagia

Today we discussed an unfortunate case of dermatomyositis presenting as dysphagia and dysphonia. While this atypical presentation of an uncommon illness is interesting to ponder, more practical learning points should still be emphasized, particularly along the lines of management of dysphagia. Most of the learning points below come from a nice AFP review article from 2000 (AFP 2000; 61: 3639).

1. How do you differentiate oropharyngeal from esophageal dysphagia? This is an important distinction as the differential diagnosis primarily splits between these two patterns. Oropharyngeal dysphagia is typically defined as difficulty initiating a swallow. These patients complain of coughing/choking/nasal regurgitation and the differential settles around neuromuscular causes of dysphagia. Esophageal dysphagia is typically defined as a sensation of food sticking in the chest or throat. The differential here settles around mechanical obstructions and motility disorders. 

2. What initial tests should be ordered based on your suspicion for either etiology? It depends, but in general, a barium esophogram is a reasonable first step if esophageal dysphagia is suspected. When oropharyngeal dysphagia is suspected, a barium swallow is performed, which is a more challenging and expensive test usually, but evaluates oropharyngeal swallowing with better precision.