About half of the patients with dysphagia present first to an otolaryngologist.
He should therefore know how to manage the condition and how to decide
which cases should be referred to a thoracic surgeon or to a gastro-enterologist,
and which cases are best dealt with by his own discipline. This chapter will
therefore aim to give some guidelines on how to approach the problem, and to
make the above decisions. Although an outline description of the commonest
oesophageal conditions will be given, it is to be appreciated that it is impossibk
to present an exhaustive treatise on oesophageal disease in a chapter of a book
of this type.
Dysphagia is an all-embracing term meaning difficulty in swallowing, but
there are all shades of difficulty ranging from a mere local discomfort to a
total hold-up to the passage of food.
The first thing to establish is the nature of the symptoms which are presented
by the patient with phrases such as 'food won't go down', 4food sticks*,
*food comes back up*, I've got a feeling of a lump in my throat', etc. It will be
appreciated that there is a very distinct difference between food not passing
and a mere feeling of discomfort in the throat.
The site of the problem is important. The oesophagus is shorter than one
thinks—it begins just above the suprasternal notch—and symptoms at the
oesophagogastric junction are often located at the xiphi-steraal notch.
Patients are remarkably accurate in siting oesophageal problems. An example
of this accuracy at the upper end is illustrated by the fact that if a foreign body
is arrested just above the cricoid level the patient will point above the cricoid,
and the foreign body should be seen on mirror examination, but if foe points
below the cricoid then he will need an oesophagoscopy for visualization of the
The severity of the symptoms may be gauged by the amount of food and
fluid the patient can swallow. Generally, when the patient is only able to take
fluids or very soft foods there will be weight loss to confirm the desperate state
of affairs. An exception to this pattern of events is in achaiasia where there is
often more difficulty in swallowing fluids than solids.
Pain is not often a feature of dysphagia unless there is some degree of
oesophagitis, most commonly due to acid reflux, but is occasionally seen in
monilial oesophagitis. A very characteristic pattern of presentation of oeso-
phageal disease is pain and discomfort at the lower end with a feeling of
tightness at the cricoid level. This is due to the fact that lower-end oesophagitis
causes nefiex spasm of the cricopharyngeus muscle.