Odynophagia overview

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Historical Perspective
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Epidemiology and Demographics
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Diagnosis
History and Symptoms
Physical Examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sunny Kumar MD [2]

Overview

Odynophagia is defined as painful swallowing. It is caused by various medical conditions. It should not be confused with dysphagia, which stands for difficulty in swallowing. Common causes of odynophagia are throat infections, foreign body, acid reflex disease, tumors, or injuries.It may lead to difficulty in swallowing due to disturbing pain.

Historical Perspective

Odynophagia is a Greek word. (/oʊ-dɪnˈə-feɪˈjəˌ-jiː-ə/; from odyno- "pain" and phagō "to eat") is pain when swallowing.

Other than that there is no specific historical background of odynophagia.

Classification

There is no established system for the classification of odynophagia. However we can classify them according to causes to approach the area of involvement..

Odynophagia may be classified according to causes into two groups:

• Disorders of esophagus
• Disorders of pharynx

Pathophysiology

The pain in swallowing is induced due to conditions causing stimulation of sensory nerves innervating esophagus and pharynx.

Infections:

Infection of esophagus or pharynx causes fluid leaking in interstitial media of mucous epithelium and it produce pressure on sensory nerve terminals situated in mucousa.

Tumors:

It produce pain due to compression effect of mass on sensory nerve terminals situated in mucousa.

Foreign body:

It produce pain due to compression effect of foreign body on sensory nerve terminals situated in mucousa.

Causes

• Achalasia cardia
• Esophageal cancer
• Myasthenia gravis
• Scleroderma
• Tonsillitis
• Upper respiratory tract infections
• Zenkers diverticulum
• Gastroesophageal reflux disease

Differentiating Odynophagia from other Conditions

The causes of odynophagia are of various pathologies. Differentiating them with adjacent history and examination is helpful to narrow down the exact pathology.

Causes	Pain	History finding	Examination finding	Diagnostic test
URTI	Acute pain	Changed in voice, fever, runny nose	inflamed oral mucosa, enlarged lymph nodes or tonsils	Oral swab culture
Tumors	Dull Pain	Loss of weight and appetite, risk factors, may have dysphagia	swelling may be seen, tumor may spread to lymph nodes	Endoscopy
Foreign body	Acute pain	History of foreign body intake	Foreign body may be seen, surrounding area may be inflamed	Laryngoscopy
GERD	Buring pain	Pain worse at nights,decrease food intake but normal appetite	oral mucousa normal, mild tender epigastrium	manomatary
Esophagitis	Burning pain	Resternal pain on swallowing, food aversion, risk factor	oral mucosa normal	Endoscopy

Epidemiology and Demographics

Common causes of odynophagia have their indepndent statcis. The common causes are

Pharyngitis:

Incidence

• 2015 In the USA, the prevalence of Pharyngitis 4.8 per 100,000 people with group A strep."ABCs | Bacterial Surveillance | 2015 GAS Report | CDC".

GERD:

Prevalence

• In the USA and Europe, the prevalence of GERD ranges from low of 10,000 per 100,000 persons to high of 20,000 per 100,000 people. [1]
• In Asia, the prevalence of GERD is 5,000 per 100,000 people.

Incidence

• In the USA, the incidence of GERD is 5,400 per 100,000 persons.
• In Europe, the incidence of GERD is 840 per 100,000 persons.

Esophagitis:

Prevalence

• In the USA and Europe, the prevalence of esophagitis ranges from low of 10,000 per 100,000 persons to high of 20,000 per 100,000 people..
• In Asia, the prevalence of esophagitis is 5,000 per 100,000 people.
• The prevalence of EoE is approximately 50-100 per 100,000 individuals worldwide.

Incidence

• In the USA, the incidence of esophagitis is 5,400 per 100,000 persons.
• In Europe, the incidence of esophagitis is 840 per 100,000 persons.
• The incidence of EoE is approximately 10 per 100,000 individuals worldwide.

Risk factors

Risk factors depend on the individual risk factors of disease causing odynophagia

Natural history, complications and prognosis

The causes of odynophagia have their own independent course of progression and complication. However if disease is treated then pain is also relived with different pace depending on what the cause has been.

History and Symptoms

Odynophagia is symptom. History of patient having odynophagia will help in narrowing down the cause of odynophagia. The cornerstone of any dysphagia evaluation is a detailed history, and a thorough review of symptoms that can differentiate esophageal from oropharyngeal odynophagia and help predict the specific etiology of odynophagia. How a patient describes his or her difficulty and its timing, associated symptoms, and other characterizations may specifically denote the anatomic level of swallowing dysfunction. Following are important aspects of history which need to be addressed.

Physical examination

Physical examination of patients with odynophagia is dependent on the underlying cause.Patients with odynophagia usually appear in discomfort.May be feverish and tachycardia in case of inflammation. May have exanthem in case of viremia or bacteriuma. Neuromuscular examination of patients with odynophagia is usually normal. However in cases of URTI causing meningitis may produce symptoms of meningeal irritation.

Laboratory Findings

Common tests which should be ordered in every case are CBC, ESR/CRP and following are specific tests:

Cardiovascular	Mediastinitis	Fluid tap and C & S
Chemical / poisoning	Botulism, Chemical burns	Toxicology and Botulism ELISA
Dermatologic	Scleroderma	Antitopoisomerase-1 or Anti-Scl-70 antibodies
Drug Side Effect	ibandronate, Stevens-Johnson Syndrome	ANA profile and drug levels
Ear Nose Throat	Cricopharyngeal spasm, Epiglottitis, Glossitis, Goiter, Laryngitis,  Oral ulcers Stomatitis,  Herpangina, Retropharyngeal abscess Xerostomia	Blood culture, viral assay, throat culture, TSH
Endocrine	Diabetic neuropathy, Hyperthyroidism, Hypothyroidism, Riedel thyroiditis	HBA1C, TSH, Blood cultures
Gastroenterologic	Esophagitis, Gastritis, Intramural pseudodiverticulosis, Schatzki ring, Myoneurogastrointestinal encephalopathy syndrome, Crohn's disease, Eosinophilic esophagitis	Electrolytes, ANA profile, stool H.pylori test
Genetic	Opitz-Frias syndrome	Genetic testing PCR
Hematologic	Agranulocytosis, Lymphadenopathy	Vit B12, RBC folate, Bone marrow microscopy
Infectious Disease	Abscesses, Acute pharyngitis, Adenoiditis, Candidiasis, Chagas Disease, Cytomegalovirus, Diphtheria, Esophageal moniliasis, Flu, Herpangina, Herpes simplex virus (HSV),  Herpes stomatitis, HIV/AIDS, Mononucleosis, Mumps, Oral candidiasis, Paracoccidioidomycosis, Pharyngitis, Poliomyelitis, Rabies, Reflux esophagitis, Respiratory tract infections,  Retropharyngeal abscess, Scarlet Fever, Tetanus, Tonsillar abscess, Typhoid fever	Viral markers, Blood C & S, Throat and sputum DR & CS,Fungal markers
Musculoskeletal / Ortho	Schatzki ring, Dermatomyositis, Myasthenia Gravis	anti–acetylcholine receptor (AChR) antibody (Ab) Bone marrow microscopy, CK, Aldolase, Mi-2 (nuclear helicase protein) Antibody
Neurologic	Amyotrophic Lateral Sclerosis (ALS), Bulbar palsy, Central hypoglossal nerve paralysis,  Central vagal nucleus lesion, Cerebrovascular accident, Guillain-Barre syndrome, Huntington's chorea,  Multiple Sclerosis, Myoneurogastrointestinal encephalopathy syndrome, Neuroferritinopathy, Peripheral neuropathy, Polyradiculitis, Diabetic neuropathy, Poliomyelitis	anti-ganglioside antibodies, anti GM1 antibodies and Anti-GQ1b,Stool culture for campylobacter jejuni,trinucleotide repeat sequence "CAG", EMG, ANA profile,
Nutritional / Metabolic	Gaucher's disease, Plummer-Vinson Syndrome	Genetic testing, Vit B12, RBC folate, Bone marrow microscopy
Oncologic	Paraneoplastic syndrome	Hormone levels of Ca, vit D, Histamine, IL-1
Rheum / Immune / Allergy	Allergic swelling, Amyloidosis, Behcet's Syndrome, CREST syndrome , Crohn's disease, Dermatomyositis, Eosinophilic esophagitis,  Esophageal sarcoidosis, Graft versus host reaction, Inclusion body myositis, Myasthenia Gravis, Parkinson's Disease, Riedel thyroiditis,  Rheumatoid Arthritis, Scleroderma, Systemic Lupus Erythematosus, Systemic sclerosis, Xerostomia	ANA profile, RF factor, Bone marrow biopsy, Ca level, Vit D level, RNA polymerase types II and III ,RNP, Scl-70 , SS-A , SS-B
Sexual	Oral sex	Oral swab culture
Miscellaneous	Alcoholism, Aspiration of foreign body	blood culture, blood alcohol levels

Electrocardiogram

An electrocardiogram can be used to assess for left atrial enlargement or in viral infections also causing pericarditis It may also be used to differentiate the cause of esophageal spasm.

CT

The benefit of using CT over X-ray is that it delineates the causative agent of odynophagia with more accuracy as compared to x-ray.

MRI

An MRI of the brain can be used to exclude CVA and mass lesions of the head and neck. It is more helpful in soft tissue margins which are causing pain in swallowing.

Echocardiography or ultrasound

Echocardiography can be used to rule out cardiac causes of odynophagia.

Medical therapy

The treatment of odynophagia depends on it's etiology.

Diagnosis

To diagnose odynophagia history, examinations and in difficult scenarios scope of larynx and pharynx may be required to reach the correct diagnosis.

Treatment

Treatment of painful swalllowing is depending on treating the primary causes. However some of cases obtain benefit of using soothing agents as marshmallow plant, Sage and echinacea, Apple cider vinegar, Salt water gargle,Honey, Licorice root,Lemon water, Ginger root tea, Coconut oil, Cinnamon, Plenty of fluids, Chicken soup, Peppermint tea, Chamomile tea and Herbal throat lozenges.