Where Does Dysphagia Go on Review of Systems
Evaluating Dysphagia
Am Fam Md. 2000 Jun 15;61(12):3639-3648.
A more contempo article on dysphagia is available.
Article Sections
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Test
- Laboratory Evaluation
- Special Studies
- Final Comment
- References
Dysphagia is a problem that usually affects patients cared for by family physicians in the office, as hospital inpatients and as nursing home residents. Familiar medical issues, including cerebrovascular accidents, gastroesophageal reflux affliction and medication-related side effects, frequently lead to complaints of dysphagia. Stroke patients are at particular risk of aspiration because of dysphagia. Classifying dysphagia equally oropharyngeal, esophageal and obstructive, or neuromuscular symptom complexes leads to a successful diagnosis in lxxx to 85 percent of patients. Based on the patient history and physical examination, barium esophagram and/or gastroesophageal endoscopy can confirm the diagnosis. Special studies and consultation with subspecialists can ostend hard diagnoses and help guide treatment strategies.
Complaints of dysphagia (difficult swallowing) are mutual, especially in crumbling persons. Approximately 7 to 10 pct of adults older than 50 years accept dysphagia, although this number may be artificially low because many patients with this problem may never seek medical intendance.ane,2 Upwardly to 25 percent of hospitalized patients and 30 to 40 percent of patients in nursing homes feel swallowing problems.3,4
Epidemiology
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Examination
- Laboratory Evaluation
- Special Studies
- Final Annotate
- References
Diseases of the esophagus are among the top l reasons that patients seek medical care and, in frequency, rank alongside issues such every bit pneumonia, bronchitis and otitis media.five Conditions that cause dysphagia tin produce esophageal rupture, nutritional deficits and aspiration pneumonia. Elderly patients are at the highest risk of dysphagia and its subsequent complications, particularly silent aspiration.
Although the 2 conditions are ofttimes associated, dysphagia should exist distinguished from odynophagia (painful swallowing). In addition, care should as well be taken not to confuse globus with dysphagia. Globus is the constant sensation of a lump in the throat, although no organic defect or true difficulty in swallowing is apparent.
Anatomy and Physiology of Deglutition
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Examination
- Laboratory Evaluation
- Special Studies
- Last Comment
- References
Deglutition is the act of swallowing in which a nutrient or liquid bolus is transported from the mouth through the throat and esophagus into the stomach. Normal deglutition involves a circuitous serial of voluntary and involuntary neuromuscular contractions proceeding from the mouth to the breadbasket and is ordinarily divided into oropharyngeal and esophageal stages.
OROPHARYNGEAL STAGE
The oropharyngeal stage of deglutition begins with contractions of the tongue and striated muscles of mastication. The muscles work in a coordinated style to mix the nutrient bolus with saliva and propel it from the anterior oral fissure into the oropharynyx, where the involuntary swallowing reflex is triggered6 (Effigy 1a). The cerebellum controls output for the motor nuclei of cranial nerves V, VII and XII. The entire sequence lasts about one second.
FIGURE 1A.
The tongue initially forms the food bolus (greenish) with compression against the hard palate.
In the posterior oropharynx, a complex and precisely coordinated succession of muscular contractions and relaxations occurs. The soft palate elevates to shut the nasopharynx, and the suprahyoid muscles pull the larynx upwardly and forward6 (Figure 1b). The epiglottis moves downward to cover the airway while striated pharyngeal muscles contract to move the food bolus past the cricopharyngeus muscle (the physiologic upper esophageal sphincter and into the proximal esophagus6 (Effigy 1c). This swallowing reflex lasts approximately 1 2d and involves the motor and sensory tracts from cranial nerves Ix and X.
Figure 1B.
Displacement of the food bolus into the throat by the tongue initiates deglutition.
Figure 1C.
Relaxation of the cricopharyngeal musculus (the physiological upper esophageal sphincter) permits movement of the food bolus into the proximal esophagus.
ESOPHAGEAL STAGE
Equally nutrient is propelled from the pharynx into the esophagus, involuntary contractions of the skeletal muscles of the upper esophagus forcefulness the bolus through the mid and distal esophagus. The medulla controls this involuntary swallowing reflex, although voluntary swallowing may exist initiated past the cerebral cortex. The lower esophageal sphincter relaxes at the initiation of the consume, and this relaxation persists until the food bolus is propelled into the stomach. It may take eight to xx seconds for the contractions to drive the bolus into the stomach.7
Pathophysiology
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Test
- Laboratory Evaluation
- Special Studies
- Final Annotate
- References
Organic abnormalities of deglutition may exist related to initiation of the swallowing reflex in the oropharynx or to propulsion of the food bolus through the esophagus (Table ane).eight
Table 1.
Differential Diagnoses of Dysphagia
| Oropharyngeal dysphagia | Esophageal dysphagia | |||||
|---|---|---|---|---|---|---|
| Neuromuscular affliction | Neuromuscular disorders | |||||
| Diseases of the central nervous system | Achalasia | |||||
| Cerebrovascular accident | Spastic motor disorders | |||||
| Parkinson's disease | Diffuse esophageal spasm | |||||
| Brain stalk tumors | Hypertensive lower esophageal sphincter | |||||
| Degenerative diseases | Nutcracker esophagus | |||||
| Amyotrophic lateral sclerosis | Scleroderma | |||||
| Multiple sclerosis | Obstructive lesions | |||||
| Huntington'south disease | Intrinsic structural lesions | |||||
| Postinfectious | Tumors | |||||
| Poliomyelitis | Strictures | |||||
| Syphilis | Peptic | |||||
| Peripheral nervous arrangement | Radiation-induced | |||||
| Peripheral neuropathy | Chemical-induced | |||||
| Motor cease-plate dysfunction | Medication-induced | |||||
| Myasthenia gravis | Lower esophageal rings (Schatzki'southward ring) | |||||
| Skeletal muscle disease (myopathies) | Esophageal webs | |||||
| Polymyositis | Foreign bodies | |||||
| Dermatomyositis | Extrinsic structural lesions | |||||
| Muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy) | Vascular pinch | |||||
| Cricopharyngeal (upper esophageal sphincter), achalasia | Enlarged aorta or left atrium | |||||
| Obstructive lesions | Aberrant vessels | |||||
| Tumors | Mediastinal masses | |||||
| Inflammatory masses | Lymphadenopathy | |||||
| Trauma/surgical resection | Substernal thyroid | |||||
| Zenker'south diverticulum | ||||||
| Esophageal webs | ||||||
| Extrinsic structural lesions | ||||||
| Anterior mediastinal masses | ||||||
| Cervical spondylosis | ||||||
In oropharyngeal dysphagia, symptoms arise from the dysfunctional transfer of a nutrient bolus in the pharynx past the upper esophageal sphincter into the esophagus. Oropharyngeal dysphagia is about common in elderly patients and frequently presents as part of a broader complex of signs and symptoms that lead the dr. to a correct principal diagnosis. Stroke is the leading cause of oropharyngeal dysphagia.8
Esophageal dysphagia is acquired past disordered peristaltic move or weather that obstruct the catamenia of a food bolus through the esophagus into the breadbasket. Achalasia and scleroderma are the leading motility disorders, while carcinomas, strictures and Schatzki'southward rings are the near mutual obstructive lesions.
History
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Exam
- Laboratory Evaluation
- Special Studies
- Final Comment
- References
Patients who have dysphagia may nowadays with a diverseness of complaints, merely they usually report coughing or choking, or the abnormal sensation of food sticking in the dorsum of the throat or upper breast when they are trying to swallow. A carefully conducted patient history volition enable the physician to identify 80 to 85 percent of the causes of dysphagia. Specific questions well-nigh the onset, duration and severity of the dysphagia, and a multifariousness of associated symptoms (Table 2)9 may assistance narrow the differential diagnoses to a specific diagnosis or to an anatomic or pathophysiologic-related diagnosis.
Tabular array 2.
Associated Symptoms and Possible Etiologies of Dysphagia
| Status | Diagnoses to consider | ||
|---|---|---|---|
| Progressive dysphagia | Neuromuscular dysphagia | ||
| Sudden dysphagia | Obstructive dysphagia, esophagitis | ||
| Difficulty initiating consume | Oropharyngeal dysphagia | ||
| Food "sticks" after consume | Esophageal dysphagia | ||
| Coughing | |||
| Early in swallow | Neuromuscular dysphagia | ||
| Tardily in swallow | Obstructive dysphagia | ||
| Weight loss | |||
| In the elderly | Carcinoma | ||
| With regurgitation | Achalasia | ||
| Progressive symptoms | |||
| Heartburn | Peptic stricture, scleroderma | ||
| Intermittent symptoms | Rings and webs, diffuse esophageal spasm, nutcracker esophagus | ||
| Pain with dysphagia | Esophagitis | ||
| Postradiation | |||
| Infectious: herpes simplex virus, monilia | |||
| Pill-induced | |||
| Pain made worse by: | |||
| Solid food but | Obstructive dysphagia | ||
| Solids and liquids | Neuromuscular dysphagias | ||
| Regurgitation of old food | Zenker's diverticulum | ||
| Weakness and dysphagia | Cerebrovascular accidents, muscular dystrophies, myasthenia gravis, multiple sclerosis | ||
| Halitosis | Zenker's diverticulum | ||
| Dysphagia relieved with repeated swallows | Achalasia | ||
| Dysphagia fabricated worse with cold foods | Neuromuscular motility disorders | ||
A patient's full general health information should be reviewed, including long-term illnesses, electric current prescription medications, and alcohol and tobacco use. While the literature does not describe dysphagia caused by non-prescription drugs, it is always reasonable to inquire about this. Commonly prescribed medications can cause dysphagia in either the oropharyngeal or esophageal stages of swallowing (Tabular array 3).10,11 Antibiotics (doxycycline [Vibramycin], tetracycline, clindamycin [Cleocin], trimethoprim-sulfamethoxazole [Bactrim, Septra]) and nonsteroidal anti-inflammatory drugs are the most common causes of directly mucosal injury to the esophagus, while potassium chloride tablets can cause the about severe injury. Anticholinergics, alpha adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors and many brusque- and long-acting antihistamines tin crusade xerostomia.
Tabular array 3.
Medications Associated with Dysphagia
| Medications that can cause direct esophageal mucosal injury 10 |
| Antibiotics |
| Doxycycline (Vibramycin) |
| Tetracycline |
| Clindamycin (Cleocin) |
| Trimethoprim-sulfamethoxazole (Bactrim, Septra) |
| Nonsteroidal anti-inflammatory drugs |
| Alendronate (Fosamax) |
| Zidovudine (Retrovir) |
| Ascorbic acid |
| Potassium chloride tablets (Slow-Thousand)* |
| Theophylline |
| Quinidine gluconate |
| Ferrous sulfate |
| Medications, hormones and foods associated with reduced lower esophageal sphincter tone and reflux 11 |
| Butylscopolamine |
| Theophylline |
| Nitrates |
| Calcium antagonists |
| Alcohol, fat, chocolate |
| Medications associated with xerostomia 11 |
| Anticholinergics: atropine, scopolamine (Transderm Scop) |
| Alpha adrenergic blockers |
| Angiotensin-converting enzyme inhibitors |
| Angiotensin II receptor blockers |
| Antiarrhythmics |
| Disopyramide (Norpace) |
| Mexiletine (Mexitil) |
| Ipratropium bromide (Atrovent) |
| Antihistamines |
| Diuretics |
| Opiates |
| Antipsychotics |
A carefully conducted patient history should answer two general questions: (ane) is the dysphagia oropharyngeal or esophageal in nature and (two) is information technology caused by mechanical obstacle or a neuromuscular movement disorder?8 Figure 2 eight presents an algorithmic approach to the history.
Differential Diagnosis of Dysphagia
Effigy 2.
Differentiating symptoms of dysphagia.
Information from Castell DO. Arroyo to the patient with dysphagia. In: Yamada T, ed. Textbook of gastroenterology. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 1995.
OROPHARYNGEAL LOCALIZATION
Patients with oropharyngeal dysphagia present with difficulty in initiating swallowing and may likewise take associated coughing, choking or nasal regurgitation. The patient's spoken communication quality may accept a nasal tone. These dysphagias are most frequently associated with stroke, Parkinson's illness or other long-term neuromuscular disorders. Local structural lesions are less common.
ESOPHAGEAL LOCALIZATION
Patients with esophageal dysphagia present with the sensation of nutrient sticking in their pharynx or chest. The patient's description of the perceived location of the obstruction often does not correlate well with bodily pathology, specially if the perceived location is in the cervical area. Motility disorders and mechanical obstructions are mutual. Several medications have been associated with direct esophageal mucosal injury while others tin decrease lower esophageal sphincter pressures and cause reflux (Table three).ten,xi
NEUROMUSCULAR Movement DISORDERS
Patients with neuromuscular dysphagia experience gradually progressive difficulty in swallowing solid food and liquids. Common cold foods oftentimes beal the problem. Patients may succeed in passing the food bolus by repeated swallowing, past performing the Valsalva maneuver or by making a positional change. They are more than likely to feel hurting when swallowing than patients with uncomplicated obstruction. Achalasia, scleroderma and diffuse esophageal spasm are the most common causes of neuromuscular motion disorders.
MECHANICAL OBSTRUCTION
Obstructive pathology is typically associated with dysphagia of solid nutrient but not liquids. Patients may be able to forcefulness food through the esophagus by performing a Valsalva maneuver, or they may regurgitate undigested nutrient. Shut questioning of the patient may reveal a change in diet to one of predominantly soft foods. Speedily progressive dysphagia of a few months' duration suggests esophageal carcinoma. Weight loss is more predictive of a mechanical obstructive lesion.12 Peptic stricture, carcinoma and Schatzki'due south band are the predominant obstructive lesions.
Concrete Examination
- Abstruse
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Physical Exam
- Laboratory Evaluation
- Special Studies
- Last Comment
- References
A general physical examination and focused organ- or symptom-specific examinations based on the patient'due south history oft identify the etiology of dysphagia.
Neurologic evaluation should include assessments of the patient's mental status, motor and sensory functioning, deep tendon reflexes and cranial nerves, and a cerebellar examination. Patients with impaired cognitive functioning and those who are under sedation should be carefully assessed, because these neurologic states can interfere with swallowing. Motor and sensory examinations may reveal a new stroke or identify a long-term disease. Special attention should exist focused on the cranial fretfulness that are associated with swallowing, specially the motor components of cranial nerves 5, VII, IX, X and XII, and sensory fibers from cranial nerves V, VII, IX and X. A decreased gag reflex is associated with an increased run a risk of aspiration.13 A "wet voice" may suggest long-term laryngeal aspiration, while a weak, breathy voice may indicate vocal string pathology.
Adequate saliva production results in a pinkish, well-hydrated oral cavity. Certain medications induce xerostoma preventing adequate mixing and propulsion of the food bolus into the posterior oropharynx (Table 3).10,11 A tongue blade and handheld mirror allow indirect inspection of the soft palate and song cord mobility. Physicians who are skilled in nasopharyngoscopy tin directly view the song cords and hypopharynx. Bimanual palpation of the floor of the mouth, tongue and lips with a gloved hand detects masses and aberrant motor function. Exam of the teeth tin reveal signs of inflammation or other structural disorders.
Observing the patient swallowing a variety of liquids and solids can exist 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 cough. Elevation of the larynx during the swallowing reflex protects the airway and opens the upper esophageal sphincter. Normal laryngeal rising can exist palpated by placing the index finger above the patient's thyroid cartilage when the patient swallows. The cartilage should move cephalad confronting the physician'south finger.
Thyroid masses and lymphadenopathy that cause obstructive dysphagia can be palpated on examination of the neck. A widened anteroposterior chest bore and distant breath sounds are signs of chronic obstructive pulmonary disease, which could exist acquired by long-term aspiration. The patient'due south abdomen should exist examined for masses and organomegaly. The presence of occult blood in the stool may exist a sign of neoplasms or esophagitis.
Laboratory Evaluation
- Abstruse
- Epidemiology
- Beefcake and Physiology of Deglutition
- Pathophysiology
- History
- Physical Examination
- Laboratory Evaluation
- Special Studies
- Final Annotate
- References
Initial laboratory evaluations should exist limited to specific studies based on the differential diagnosis generated afterward the completion of a history and physical examination. A consummate blood count screens for infectious or inflammatory atmospheric condition. Thyroid part studies may detect hypo- or hyperthyroid-associated causes of dysphagia (east.thousand., Grave's affliction or thyroid carcinoma). Other studies should be based on specific clinical conditions.
Special Studies
- Abstract
- Epidemiology
- Anatomy and Physiology of Deglutition
- Pathophysiology
- History
- Concrete Exam
- Laboratory Evaluation
- Special Studies
- Final Comment
- References
Although a patient history and physical exam identify the etiology of dysphagia in most patients, farther testing may be indicated to ostend the diagnosis or to establish the patient's chance of aspiration (Figure three 14 and Table 4). Subspecialists in radiology or gastroenterology volition well-nigh oftentimes conduct these tests. Some centers have multidisciplinary dysphagia teams bachelor to offer comprehensive diagnostic evaluations and therapeutic interventions.
Evaluation of Dysphagia
FIGURE 3.
An algorithmic approach to the diagnostic evaluation of dysphagia.
Adjusted with permission from Trate DM, Parkman HP, Fisher RS. Dysphagia. Evaluation, diagnosis, and treatment. Prim Care 1996;23:417–32.
Table four.
Adjunct Studies to Evaluate Patients with Dysphagia
| Barium swallow studies |
| Suspected obstructive lesion (e.g., Schatzki'south band, tumor) |
| Suspected esophageal motility disorder |
| Double-contrast upper gastrointestinal evaluation |
| Suspected esophageal mucosal injury |
| Evaluation of oropharyngeal anatomy and role (fluoroscopy) |
| Suspected gastroesophageal reflux disease |
| Gastroesophageal endoscopy |
| Suspected acute obstructive lesion (impacted nutrient bolus) |
| Evaluation of the esophageal mucosa |
| Confirmation of a positive barium study with biopsies or cytology |
| Manometry |
| Abnormality not identified on barium study or by endoscopy |
| pH monitoring |
| Suspected gastroesophageal reflux disease |
| Videoradiography |
| Suspected gamble of aspiration |
NASOPHARYNGOSCOPY
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 straight 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 take chances of pulmonary complications.
BARIUM STUDIES
A barium written report (esophagram) is often the kickoff stride in evaluating patients with dysphagia, especially if an obstructive lesion is suspected. It identifies intrinsic and extrinsic structural lesions merely lacks precision in identifying the nature of obstructive lesions. A barium report assesses move better than endoscopy and is relatively inexpensive with few complications; nonetheless, it can be hard to perform in sick or uncooperative patients.
Double-dissimilarity studies provide better visualization of esophageal mucosa. Barium marshmallows or pills localize obstructive lesions in the oral fissure or esophagus. Fluoroscopy can identify abnormalities in the mouth and oropharynx and, if observed closely, can provide some detail nigh part, detecting reflux and abnormal peristalsis.
ENDOSCOPY
Gastroesophageal endoscopy provides the best assessment of the esophageal mucosa.fifteen Masses or other lesions identified by barium studies should initiate esophagogastroscopy with biopsy and cytology. In patients with astute 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 office or subtle strictures as well as barium studies15 (its sensitivity for detecting Schatzki's rings is but 58 percent, compared with 95 per centum for barium study), a consensus console making final diagnoses in patients with dysphagia constitute that for all dysphagia diagnoses, gastroesophageal endoscopy is more than sensitive (92 percentage versus 54 percent) and more than specific (100 percent versus 91 percentage) than double-contrast upper gastrointestinal radiography.16 One writer suggests that the college cost of gastroesophageal endoscopy may exist offset by lower subsequent medical costs because of its improved accurateness in diagnosing dysphagia.17
VIDEORADIOGRAPHIC STUDIES
Patients at take chances for silent aspiration (e.g., stroke, neurologic impairment) may benefit from videoradiographic studies that are performed by a team composed of a radiologist, an otolaryngologist and a speech pathologist with expertise in swallowing disorders.17 This evaluation uses quantifiable measures of swallows of a variety of bolus consistencies to help considerately identify the presence, nature and severity of oropharyngeal swallowing problems and to assess treatment options. Compared with upper gastrointestinal radiography, videoradiographic studies are improve in identifying patients with balmy strictures and extrinsic compressions (eastward.g., tumors or osteoarthritic spurs of the vertebrae).12 These studies are more expensive because of the special expertise, equipment and facilities required.
MANOMETRY
Manometry assesses motor office of the esophagus and is indicated if no abnormality is identified by barium study or gastroesophageal endoscopy.18 A catheter with multiple electronic pressure probes is passed into the tummy, measuring esophageal contractions and defining upper and lower esophageal responses to swallowing. Manometry detects definitive abnormalities in merely 25 per centum of patients with nonobstructive lesions. Its use in disorders of the oropharyngeal upper esophageal sphincter is not particularly effective, because patients do non tolerate the procedure well.
PH MONITORING
Despite several drawbacks, esophageal pH monitoring remains the gilt standard for diagnosing patients with suspected reflux affliction.19 A nasogastric probe is inserted into the patient's esophagus and records pH levels. These levels are compared with the patient's tape of symptoms over a 24-hour menstruum to determine if acrid reflux contributes to the symptoms. Combined recordings of esophageal pH levels and intraluminal esophageal pressure may assistance in diagnosing patients with reflux-induced esophageal spasm.
OTHER IMAGING TECHNIQUES
Evidently radiographic films of the breast or neck offering limited information unless structural abnormalities are noted. Computed tomography and magnetic resonance imaging scans provide excellent definition of structural abnormalities, peculiarly 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 help in the evaluation of submucosal and extramural lesions of the esophagus. Radionuclide studies may be used to evaluate transit function through the esophagus.
Last Comment
- Abstruse
- Epidemiology
- Beefcake and Physiology of Deglutition
- Pathophysiology
- History
- Physical Examination
- Laboratory Evaluation
- Special Studies
- Terminal Comment
- References
Family unit physicians can reduce the symptoms and risks of complications by early and aggressive evaluation and direction of stroke patients. Physicians should recommend that all patients, especially the elderly, have their medications with a total glass of h2o while in an upright position well earlier bedtime. Patient referral is warranted when the crusade of dysphagia is unclear, when at that place is evidence of aspiration or if further diagnostic or therapeutic expertise is necessary.
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REFERENCES
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i. Lindgren S, Janzon 50. Prevalence of swallowing complaints and clinical findings among 50–79-yr-old men and women in an urban population. Dysphagia. 1991;vi:187–92. ...
2. Tibbling L, Gustafsson B. Dysphagia and its consequences in the elderly. Dysphagia. 1991;half dozen:200–ii.
3. Brin MF, Younger D. Neurologic disorders and aspiration. Otolaryngol Clin North Am. 1988;21:691–9.
4. Layne KA, Losinski DS, Zenner PM, Ament JA. Using the Fleming index of dysphagia to found prevalence. Dysphagia. 1989;iv:39–42.
v. Nelson C, Woodwell D. National Ambulatory Medical Care Survey: 1993 summary. Vital Wellness Stat. 13 1998iiivi1–99.
6. Schuller DE, Schleuning AJ, DeWeese DD, Saunders WH. DeWeese and Saunders' Otolaryngology—caput and neck surgery. 8th ed. Schuller DE, Schleuning AJ, eds. St. Louis: Mosby, 1994.
vii. Logemann JA. Evaluation and treatment of swallowing disorders. San Diego: College-Hill, 1983.
8. Castell DO. Approach to the patient with dysphagia. In: Yamada T, ed. Textbook of gastroenterology. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 1995.
9. Johnson A. Deglutition. In: Scott-Brown WG, Kerr AG. Scott-Brownish'southward Otolaryngology. sixth ed. Boston: Butterworth-Heinemann, 1997.
ten. Boyce HW. Drug-induced esophageal damage: diseases of medical progress. [Editorial] Gastrointest Endosc. 1998;47:547–50.
11. Stoschus B, Allescher HD. Drug-induced dysphagia. Dysphagia. 1993;8:154–ix.
12. Kim CH, Weaver AL, Hsu JJ, Rainwater L, Zinsmeister AR. Discriminate value of esophageal symptoms: a study of the initial clinical findings in 499 patients with dysphagia of various causes. Mayo Clin Proc. 1993;68:948–54.
13. Horner J, Massey EW. Silent aspiration following stroke. Neurology. 1988;38:317–ix.
xiv. Trate DM, Parkman HP, Fisher RS. Dysphagia. Evaluation, diagnosis, and handling. Prim Care. 1996;23:417–32.
fifteen. Cooper GS. Indications and contraindications for upper gastrointestinal endoscopy. Gastrointest Endosc Clin Northward Am. 1994;four:439–54.
16. Dooley CP, Larson AW, Stace NH, Renner IG, Valenzuela JE, Eliasoph J, et al. Double-dissimilarity barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med. 1984;101:538–45.
17. Castell JA, Stumacher SG, Castell DO. Arroyo to patients with oropharyngeal dysphagia. Gastroenterologist. 1994;2:14–ix.
18. Feussner H, Kauer W, Siewert JR. The identify of esophageal manometry in the diagnosis of dysphagia. Dysphagia. 1993;8:98–104.
19. Bollschweiler East, Feussner H, Holscher AH, Siewert JR. pH monitoring: the gilded standard in detection of gastrointestinal reflux disease? Dysphagia. 1993;8:118–21.
Members of various family practice departments develop manufactures for "Trouble-Oriented Diagnosis." This article is one in a serial coordinated by the Section of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Doc. Guest editors of the series are Francis Grand. O'Connor, LTC, MC, United states, and Jeannette E. South-Paul, COL, MC, United states.
Copyright © 2000 by the American Academy of Family Physicians.
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