Dysphagia is difficulty swallowing. This may have local mechanical causes which are usually gastroenterological in origin (tumor; peptic ulceration/stricture, in which case there may be additional pain on swallowing-odynophagia) but sometimes vascular (aberrant right subclavian artery – dysphagia lusoria). Dysphagia of neurological origin may be due to pathology occurring anywhere from cerebral cortex to muscle. Neurological control of swallowing is bilaterally represented and so unilateral upper motor neurone lesions may cause only transient problems. Poststroke dysphagia is common, but there is evidence of cortical reorganization (neuroplasticity) underpinning recovery. Bilateral upper motor neurone lesions cause persistent difficulties. Dysphagia of neurological origin may be accompanied by dysphonia, palatal droop, and depressed or exaggerated gag reflex.
Recognized neurological causes of dysphagia include:
- Upper motor neurone pathology: pseudobulbar palsy, e.g., motor neurone disease, bilateral cerebrovascular disease, multiple sclerosis
- Lower motor neurone pathology: bulbar palsy, isolated vagus (X)
nerve palsy, jugular foramen syndrome
- Autonomic neuropathy, e.g., Chagas’ disease, Riley Day syndrome
- Neuromuscular junction pathology: myasthenia gravis
- Muscular pathology: polymyositis, oculopharyngeal muscular dystrophy.
Difficulty swallowing may on occasion be functional in origin (globus hystericus).
If swallowing is compromised with a risk of aspiration, feeding may need to be undertaken via nasogastric tube, percutaneous gastrostomy or jejunostomy placed endoscopically (PEG or PEJ), or even parenterally.
Hamdy S, Aziz Q, Rothwell JC, Singh KD, Barlow J, Hughes DG, Tallis RC, Thompson DG. The cortical topography of human swallowing musculature in health and disease. Nature Medicine1996; 2: 1217-1224
Logemann JA. Approach to the patient with dysphagia. In: Biller J (ed.). Practical neurology (2nd edition). Philadelphia: Lippincott Williams & Wilkins, 2002: 227-235