Odynophagia overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Odynophagia from other Conditions

Epidemiology and Demographics

Screening

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

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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 is 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. Odynphagia is a word with Greek origin. There is no established system for the classification of odynophagia. However we can classify them according to causes to approach the area of involvement. The pain in swallowing is induced due to conditions causing stimulation of sensory nerves innervating esophagus and pharynx. Several diseases, such as, Achalasia cardia, Esophageal cancer, Myasthenia gravis, Scleroderma, Tonsillitis, upper respiratory tract infections, Zenkers diverticulum and Gastroesophageal reflux disease have Odynophagia as one of its presenting symptoms and thus, it is essential to differentiate these diseases from one another.

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 which include disorders of esophagus and disorders of pharynx.

Pathophysiology

The pain in swallowing is induced due to conditions causing stimulation of sensory nerves innervating esophagus and pharynx. Infections of esophagus or pharynx cause fluid to leak into the interstitial media of mucous epithelium and it produce pressure on sensory nerve terminals situated in the mucosa. Tumors produce pain due to compression effect of mass on sensory nerve terminals situated in mucosa. Foreign body produce pain due to compression effect of foreign body on sensory nerve terminals situated in mucosa.

Causes

There are several diseases that present with odynophagia. Some of them include Achalasia cardia, Esophageal cancer, Myasthenia gravis, Scleroderma,Tonsillitis, Upper respiratory tract infections, Zenkers diverticulum and 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.

Epidemiology and Demographics

Common causes of Odynophagia have their independent statistics. In 2015, In the USA, the prevalence of Pharyngitis was 4.8 per 100,000 people with group A strep. The prevalence of GERD In the USA and Europe ranges from low of 10,000 per 100,000 persons to high of 20,000 per 100,000 people. In Asia, the prevalence of GERD is 5,000 per 100,000 people. The prevalence of esophagitis In the USA and Europe 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.

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 a symptom. History of patient presenting with painful swallowing 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.

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 tachycardic in case of inflammation. May have exanthem in case of viremia or bacteremia. 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 BotulismChemical burns Toxicology and Botulism ELISA
Dermatologic Scleroderma Antitopoisomerase-1 or Anti-Scl-70 antibodies
Drug Side Effect ibandronateStevens-Johnson Syndrome ANA profile and drug levels
Ear Nose Throat Cricopharyngeal spasmEpiglottitisGlossitisGoiterLaryngitis,  Oral ulcers Stomatitis,  HerpanginaRetropharyngeal abscess Xerostomia Blood culture, viral assay, throat culture, TSH
Endocrine Diabetic neuropathyHyperthyroidismHypothyroidismRiedel thyroiditis HBA1C, TSH, Blood cultures
Gastroenterologic EsophagitisGastritis, Intramural pseudodiverticulosis, Schatzki ringMyoneurogastrointestinal encephalopathy syndromeCrohn's diseaseEosinophilic esophagitis Electrolytes, ANA profile, stool H.pylori test
Genetic Opitz-Frias syndrome Genetic testing PCR
Hematologic AgranulocytosisLymphadenopathy Vit B12, RBC folate, Bone marrow microscopy
Infectious Disease AbscessesAcute pharyngitisAdenoiditisCandidiasisChagas DiseaseCytomegalovirusDiphtheriaEsophageal moniliasisFluHerpanginaHerpes simplex virus (HSV)

Herpes stomatitisHIV/AIDSMononucleosisMumpsOral candidiasisParacoccidioidomycosisPharyngitisPoliomyelitisRabiesReflux esophagitisRespiratory tract infections,

 Retropharyngeal abscessScarlet FeverTetanusTonsillar abscessTyphoid fever

Viral markers, Blood C & S,

Throat and sputum DR & CS,Fungal markers

Musculoskeletal / Ortho Schatzki ringDermatomyositisMyasthenia Gravis anti–acetylcholine receptor (AChR) antibody (Ab)

Bone marrow microscopy, CK, Aldolase,

Mi-2 (nuclear helicase protein) Antibody

Neurologic Amyotrophic Lateral Sclerosis (ALS)Bulbar palsyCentral hypoglossal nerve paralysis

Central vagal nucleus lesionCerebrovascular accidentGuillain-Barre syndromeHuntington's chorea

Multiple SclerosisMyoneurogastrointestinal encephalopathy syndromeNeuroferritinopathyPeripheral neuropathyPolyradiculitisDiabetic neuropathyPoliomyelitis

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 diseasePlummer-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 swellingAmyloidosisBehcet's SyndromeCREST syndrome , Crohn's diseaseDermatomyositisEosinophilic esophagitis

Esophageal sarcoidosisGraft versus host reactionInclusion body myositisMyasthenia GravisParkinson's DiseaseRiedel thyroiditis,

 Rheumatoid ArthritisSclerodermaSystemic Lupus ErythematosusSystemic sclerosisXerostomia

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 AlcoholismAspiration 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.

Chest x ray

The use of radiography of chest may help in differentiating multiple causes of chest cavity causing odynophagia.

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. Approaching patient with Odynophagia

 
 
 
 
 
 
Alarm findings:
Odynophagia
Dysphagia
Weight loss
Anorexia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If present:
upper gut endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If normal
Proton pump inhibitors
therapeutic or empirical
 
 
 
 
 
 
If mucousal abnormality
seen than treat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient benefits
taper dose and maintain
 
 
 
 
 
 
 
If no benefit
order manomatery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manomatery shows
Achlasia
 
 
Manomatery shows
Spastic motility disorders
Nutcracker esophagus
DES
Hypertonic LES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with
medicine
surgery
endoscopic procedure
 
 
 
 
 
 
 
 
 
Manomatery shows
Normal tone
Trear with pain killers
 
 
 
 
 
 

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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.

Surgery

Conditions causing pain on swallowing such as tumors, chronic inflammation inducing stricture, neuropathies not responding to medications or rings may need surgery to relive narrowing. As narrowing is resolved then food passage is smooth and pain is relived. Most of the conditions not responding to medication benefits with balloon dilation of narrowing.

Primary Prevention

Odynophagia can be prevented primarily by avoiding the conditions causing it. Earlier diagnosis of tumors and treatment of conditions causing inflammation of upper rerespiratory tract or upper GI tract will reduce the chances of development of odynophgia.

Secondary prevention

The conditions causing odynophaiga are treatable. Once the pathological causing odynophaiga are treated then pain on swallowing also improves. However soothing agents help in faster recovery when primary cause id addressed.

Cost-effectiveness of therapy

The maneuvers giving soothing effect to throat may be helpful cost effective remedies. Following are soothing remedies as use of 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

References

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