Dysphagia causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2]Kiran Singh, M.D. [3]

Overview

Life threatening causes of dysphagia include lead poisoning, rabies, and stroke. Other common causes of dysphagia include food impaction, gastroesophageal reflux, and pharyngitis.

Causes

Dysphagia has a couple of categories of causes which can be classified on the basis of location and the organ system involved.

Common Causes of Oropharyngeal Dysphagia

Common causes of oropharyngeal dysphagia
Neurological causes	Medications	Other causes
Stroke Parkinson's disease Occulopharyngeal dystrophy Amyotrophic lateral sclerosis Myasthenia gravis	Sedatives Hypnotic agents anticonvulsants neuroleptics antihistamines barbiturates Antiseizure medication Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples: corticosteroids, tetracycline, L-tryptophan, and anticholinergics	Radiotherapy of the head and neck Pharyngitis Cervical web or rings Dental problems

Life Threatening Causes

• Lead poisoning
• Rabies
• Stroke
• Tetanus

Common Causes

• Food impaction
• Gastroesophageal reflux
• Oral candidiasis
• Pharyngitis

Rare causes

• Scleredema adultorum
• Post chemotherapy and radiation therapy
• Descending thoracic aorta aneurysm
• Hypertrophy of cricopharyngeal muscles

Causes by Organ System

The causes of dysphagia are as follows:

Cardiovascular	Aberrant subclavian artery, amyloidosis, anomalous left pulmonary artery,aortic aneurysm, aortic arch anomalies, charge syndrome, double aortic arch, enlarged aorta, enlarged left atrium, hypokalemia, mitral valve stenosis, pericarditis, superior vena cava syndrome
Chemical / poisoning	Arizona bark scorpion poisoning, arsenic poisoning, botulism, cobra poisoning, fluoride poisoning, lead poisoning
Dermatologic	Behcet's syndrome, dermatomyositis, polymyositis, Stevens-Johnson syndrome, systemic lupus erythematosus
Drug Side Effect	Antipsychotic medications, artemether and lumefantrin, atropine, botulinum toxin, bicalutamidechemotherapy, cyclosporine toxicity, cytarabine, dactinomycin, doxycycline, eletriptan, hydroxocobalaminhyoscyamine, ibandronate, ioxilan, ixabepilone, minocycline hydrochloride, nabumetone, neuroleptics, oxcarbazepine, pergolide, rimabotulinumtoxinb, riociguat, ropinirole, sargramostim, sertraline, scarlet fever, tiagabine
Ear Nose Throat	Carcinoma of the vocal tract, cricopharyngeal spasm, eagle syndrome, epiglottitis, Impaired sensitivity in the larynx, laryngeal cancer, nasopharyngeal carcinoma, oral pharyngeal disorders, oral submucous fibrosis, palatine tonsil, pharyngeal pouch, pharyngitis, pharynx cancer, quinsy, retropharyngeal abscess, tonsillar cancer
Endocrine	Cushing's syndrome, diabetic neuropathy, goiter, hyperthyroidism, hypokalemia, hypothyroidism, paraganglioma, Riedel thyroiditis, subacute granulomatous thyroiditis, thymoma, thyroglossal cyst, thyroid cancer, anaplastic,thyrotoxicosis, vagal paraganglioma, De Quervain's thyroiditis, solitary thyroid nodule
Environmental	No underlying causes
Gastroenterologic	Achalasia, adjustable gastric band, aerophagia, aspiration of foreign body, Barret's syndrome,candida esophagitis, cascade stomach, caustic esophagitis, Crohn's disease of the esophagus, diffuse esophageal spasm, diverticulum, eosinophilic esophagitis, eosinophilic gastroenteritis, esophageal atresia, esophageal cancer, esophageal cyst, esophageal diverticulum, esophageal leiomyoma, esophageal obstruction by a foreign body, esophageal pouch, esophageal spasm, esophageal stricture, esophageal web, esophageal moniliasis, esophageal sarcoidosis, esophageal trauma, esophagitis, esophagotracheal fistula, external esophageal compression, gastric cancer, gastric volvulus, gastritis, gastroesophageal reflux, gastrointestinal stromal tumor, gastroparesis, Gaucher disease, globus pharyngis, globus syndrome, hiatal hernia, hypertensive lower esophageal sphincter, infectious esophagitis, intramural pseudodiverticulosis, lymphocytic esophagitis, mitochondrial neurogastrointestinal encephalopathy syndrome, mucositis, myoneurogastrointestinal encephalopathy syndrome, nutcracker esophagus, odynophagia, peptic esophagitis, post surgery, peptic stricture, pharyngeal pouch, pill esophagitis, Plummer-Vinson syndrome, presbyphagia, pseudoachalasia, pyloric stenosis, radiation esophagitis, Schatzki ring, stomach cancer, upper oesophageal sphincter dysfunction, Wilson disease, zenker's diverticulum
Genetic	Aberrant subclavian artery, achalasia-addisonian syndrome, achromatopsia, adrenoleukodystrophy, ataxia neuropathy spectrum,Behcet's syndrome, chromosome 1p36 deletion syndrome, chromosome 22 ring, chromosome 22 trisomy mosaic, connective tissue disease, crisponi syndrome, Emanuel syndrome  , extreme spinal curvature, Gaucher disease,Huntington disease, lissencephaly, type 1, x-linked , muscular dystrophy, Duchenne and Becker type ,myotonic dystrophy, nemaline myopathy1, oculopharyngeal muscular dystrophy, Opitz-frias syndrome, pseudoadrenoleukodystrophy, spinal muscular atrophy type I, spinocerebellar ataxia 17  , spinocerebellar ataxia 22, spinocerebellar ataxia, autosomal recessive 1, Stuve-wiedemann dysplasia, vascular ring with right aortic arch, Wiedemann–Rautenstrauch syndrome, Wilson disease
Hematologic	Agranulocytosis, mononucleosis, Plummer-Vinson syndrome
Iatrogenic	No underlying causes
Infectious Disease	Abscess, angina tonsillaris, botulism, candida esophagitis, Chagas disease, cytomegalovirus, diphtheria, epiglottitis, gastritis, herpangina, herpes simplex virus, infectious esophagitis,laryngeal papillomatosis, lassa fever, Ludwig's angina, lyme disease, lymph granulomatosis, Lymphadenopathy,Medication-induced esophagitis, mumps, neonatal tetanus  , oral candidiasis, paracoccidioidomycosis, Pharyngitis, polio, poliomyelitis, postpolio syndrome, quinsy, rabies, retropharyngeal abscess, snakebites, stomatitis, syphilis, tetanus, tetrodotoxin, tonsillar abscess, ulcer, Vincent's angina
Musculoskeletal / Ortho	cytoplasmic body myopathy, Diffuse idiopathic skeletal hyperostosis, distal myopathy 2, elongated styloid process, extreme spinal curvature, inclusion body myositis, muscular dystrophy, Duchenne and Becker type, osteophytes, Pierre Robin's sequence
Neurologic	10th cranial nerve disorder, amyotrophic lateral sclerosis, Arnold–Chiari malformation, ataxia neuropathy spectrum, autonomic nerve disorders, autonomic neuropathy, autosomal recessive spastic paraplegia, type 11, Avellis syndrome, Babinski–Nageotte syndrome, basal ganglia disease, basilar artery insufficiency syndrome, brain stem gliomas, brainstem stroke, brainstem tumors, pseudobulbar palsy, bulbar palsy, Canomad syndrome, carotid paraganglioma, central pontine myelinosis, central vagal nucleus lesion, central hypoglossal nerve paralysis, cerebellar Infarction, cerebellar stroke, cerebral palsy, cerebrovascular accident, congenital myasthenic syndrome, cervical osteophytes, dementia, diabetic neuropathy, dystonia, epileptic encephalopathy, early infantile, 1, fosmn syndrome, Guillain-Barre Syndrome, head trauma, Huntington disease, infantile striato-thalamic degeneration, lateral funiculus angina, lateral medullary syndrome, Lhermitte-cornil-quesnel syndrome, lissencephaly, type 1, x-linked, metabolic encephalopathies, microcephaly, mitochondrial neurogastrointestinal encephalopathy syndrome, motor neuron disease, multiple sclerosis, multiple system atrophy, muscular dystrophy, Duchenne and Becker type, myasthenia gravis, myoneurogastrointestinal encephalopathy syndrome, myopathy, myotonic dystrophy, neuroferritinopathy, neurosarcoidosis, osmotic demyelination syndrome, Pallidopyramidal syndrome, paraganglioma, paraneoplastic limbic encephalitis, Parkinson disease, peripheral neuropathy, peripheral tongue paralysis, polyradiculitis, pontocerebellar hypoplasia type 2a, primary lateral sclerosis, adult, primary motility disorders, Pseudobulbar paralysis,pseudodysphagia, secondary motility disorders, Shy-Drager syndrome, spastic paraplegia 11, autosomal recessive, spinal muscular atrophy type I, spinocerebellar ataxia 17 , spinocerebellar ataxia 22 , spinocerebellar ataxia, autosomal recessive 1, striatonigral degeneration infantile, stroke, syringobulbia, tardive dyskinesia, vagus nerve palsy, Wallenberg's syndrome
Nutritional / Metabolic	Adrenoleukodystrophy, amyloidosis, Gaucher disease, hydroxocobalamin, hypokalemia, Plummer-Vinson syndrome, Wilson disease
Obstetric/Gynecologic	Leiomyoma
Oncologic	Acoustic neuroma, brain stem gliomas, brain stem tumors, bronchial carcinoma, carcinoma of the vocal tract, carotid body tumor, chordoma, esophageal cancer, gastric cancer, laryngeal cancer, laryngeal carcinoma, leiomyoma, lymphadenopathy, malignant lung cancer, malignant mesothelioma, nasopharyngeal carcinoma, neck cancer, odontoma, Oral cavity tumor, oropharyngeal cancer, palate cancer, paraganglioma, paraneoplastic limbic encephalitis, paraneoplastic syndrome, pharynx cancer, small cell lung cancer, stomach cancer, supraglottic laryngeal cancer, throat cancer, thyroid cancer, anaplastic, tongue cancer, tonsillar cancer, vagal paraganglioma
Opthalmologic	Achromatopsia, oculopharyngeal muscular dystrophy
Overdose / Toxicity	Alcoholism
Psychiatric	Anxiety disorders, dementia, frontotemporal dementia, functional disorders, global hystericus, rumination disorder, tardive dyskinesia
Pulmonary	Bronchial carcinoma, congenital bronchogenic cyst, epiglottitis, malignant lung cancer, malignant mesotheliomamediastinal mass, mediastinitis, Ondine's curse, pharyngitis, pleuritis, sarcoidosis
Renal / Electrolyte	Hypomagnesemia primary, hypophosphatemia, systemic lupus erythematosus
Rheum / Immune / Allergy	Allergic swelling, amyloidosis, Behcet's syndrome, Canomad syndrome, cervical osteophytes, CREST syndrome, dermatomyositis, diffuse systemic sclerosi, fibrosis, graft-versus-host disease, inclusion body myositis, muscular dystrophy, oculopharyngeal muscular dystrophy, osteophytes, paraneoplastic syndrome, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, sarcoidosis, scleroderma, stomatitis, systemic lupus erythematosus, systemic sclerosis, trismus
Sexual	No underlying causes
Trauma	Head trauma
Urologic	No underlying causes
Dental	Vincent's angina
Miscellaneous	Franek-bocker-kahlen syndrome, palatoplegia, tongue conditions, vascular abnormality

Common Causes of Oropharyngeal Dysphagia

Common causes of oropharyngeal dysphagia
Neurological causes	Medications	Other causes
Stroke Parkinson's disease Occulopharyngeal dystrophy Amyotrophic lateral sclerosis Myasthenia gravis	Sedatives Hypnotic agents anticonvulsants neuroleptics antihistamines barbiturates Antiseizure medication Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples: corticosteroids, tetracycline, L-tryptophan, and anticholinergics	Radiotherapy of the head and neck Pharyngitis Cervical web or rings Dental problems

• A stroke can trigger a rapid onset of dysphagia with a high occurrence of aspiration. The function of normal swallowing may or may not return completely following an acute phase lasting approximately 6 weeks.
• Parkinson's disease can cause "multiple prepharyngeal, pharyngeal, and esophageal abnormalities". The severity of the disease most often correlates with the severity of the swallowing disorder.
• Neurologic disorders such as stroke, Parkinson's disease, amyotrophic lateral sclerosis, Bell's palsy, or myasthenia gravis can cause weakness of facial and lip muscles that are involved in coordinated mastication as well as weakness of other important muscles of mastication and swallowing.
• Oculopharyngeal muscular dystrophy is a genetic disease with palpebral ptosis, oropharyngeal dysphagia, and proximal limb weakness.
• Decrease in salivary flow, which can lead to dry mouth or xerostomia, can be due to Sjogren's syndrome, anticholinergics, antihistamines, or certain antihypertensives and can lead to incomplete processing of food bolus.
• Xerostomia can reduce the volume and increase the viscosity of oral secretions making bolus formation difficult as well as reducing the ability to initate and swallow the bolus
• Dental problems can lead to inadequate chewing.
• Abnormality in oral mucosa such as from mucositis, aphthous ulcers, or herpetic lesions can interfere with bolus processing.
• Mechanical obstruction in the oropharynx may be due to malignancies, cervical rings or webs, or cervical osteophytes.
• Increased upper esophageal sphincter tone can be due to Parkinson's disease which leads to incomplete opening of the UES. This may lead to formation of a Zenker's diverticulum.
• Pharyngeal pouches typically cause difficulty in swallowing after the first mouthful of food, with regurgitation of the pouch contents. These pouches are also marked by malodorous breath due to decomposing foods residing in the pouches. (See Zenker's diverticulum)
• Dysphagia is often a side effect of surgical procedures like anterior cervical spine surgery, carotid endarterectomy, head and neck resection, oral surgeries like removal of the tongue, and parietal laryngectomies
• Radiotherapy, used to treat head and neck cancer, can cause tissue fibrosis in the irradiated areas. Fibrosis of tongue and larynx lead to reduced tongue base retraction and laryngeal elevation during swallowing
• Infection may cause pharyngitis which can prevent swallowing due to pain.
• Medications can cause central nervous system effects that can result in an oropharyngeal dysphagia. Examples: sedatives, hypnotic agents, anticonvulsants, antihistamines, neuroleptics, barbiturates, and antiseizure medication. Medications can also cause peripheral nervous system effects resulting in an oropharyngeal dysphagia. Examples: corticosteroids, tetracycline, L-tryptophan, and anticholinergics

Common Causes of Esophageal Dysphagia

• Peptic stricture, or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to gastroesophageal reflux (GERD). These patients are usually older and have had GERD for a long time. Acid reflux can also be due to other causes, such as Zollinger-Ellison syndrome, NG tube placement, and scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present.

• Esophageal cancer also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or adenocarcinoma. Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed Barrett's esophagus (intestinal metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use.

Main article: esophageal cancer

• Esophageal rings and webs, are actual rings and webs of tissue that may occlude the esophageal lumen.

• • Rings --- Also known as Schatzki rings from the discoverer, these rings are usually mucosal rings rather than muscular rings, and are located near the gastroesophageal junction at the squamo-columnar junction. Presence of multiple rings may suggest eosinophilic esophagitis. Rings cause intermittent mechanical dysphagia, meaning patients will usually present with transient discomfort and regurgitation while swallowing solids and then liquids, depending on the constriction of the ring.

• • Webs --- Usually squamous mucosal protrusion into the esophageal lumen, especially anterior cervical esophagus behind the cricoid area. Patients are usually asymptomatic or have intermittent dysphagia. An important association of esophageal webs is to the Plummer-Vinson syndrome in iron deficiency, in which case patients will also have anemia, koilonychia, fatigue, and other symptoms of anemia.

Main article: esophageal web

• Achalasia is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of peristalsis in the distal esophagus, which is mostly smooth muscle. Both of these features impair the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids, in particular, is a characteristic of achalasia. Other symptoms of achalasia include regurgitation, night coughing, chest pain, weight loss, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. In most cases the cause is unknown (idiopathic), but in some regions of the world, achalasia can also be caused by Chagas disease due to infection by Trypanosoma cruzi.

Main article: achalasia

• Scleroderma is a disease characterized by atrophy and sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux.

Main article: scleroderma

• Spastic motility disorders include diffuse esophageal spasm (DES), nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific spastic esophageal motility disorders (NEMD).

• • DES can be caused by many factors that affect muscular or neural functions, including acid reflux, stress, hot or cold food, or carbonated drinks. Patients present with intermittent dysphagia, chest pain, or heartburn.

• Diverticulum
• Aberrant subclavian artery, or (dysphagia lusoria)
• Cervical osteophytes
• Enlarged aorta
• Enlarged left atrium
• Mediastinal tumor