A) Bacterial
There are numerous bacterial sources of infection
in the head and neck that can result in dysphagia. The most common is bacterial
tonsillitis and pharyngitis. While typically there is an associated odynophagia,
physical examination of the oral cavity and laryngopharynx will reveal erythema,
edema and sometimes an exudate. In the acute setting, treatment usually requires
antibiotic therapy, however, in select situations, tonsillectomy may be the correct
treatment option (29) (96).
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Dental
infections, when not aggressively managed can result in significant dysphagia,
at times progressing to an airway emergency. The best example is a patient with
swelling of the soft tissues of the floor of the mouth secondary to a purulent
fluid collection resulting in elevation of the floor of mouth and tongue causing
dysphagia as well as airway obstruction. This disease entity is also known as
Ludwig's angina (30)(97). The treatment, in addition to high dose antibiotic therapy,
is surgical drainage of the floor of mouth collection and, often, temporary tracheostomy.
Poorly treated, or insufficiently treated tonsil and pharynx infections can present
with dysphagia secondary to purulent fluid collection in the parapharyngeal space
of the neck. The parapharyngeal space is a potential space in the neck bounded
superiorly by the skull base, inferiorly by the hyoid bone, laterally by the pterygomandibular
raphe and medially by the lateral pharyngeal wall. The dysphagia from a parapharyngeal
space infection is the result of displacement of the lateral pharyngeal wall medially
over the hypopharynx (31) (98). Physical exam is remarkable for effacement of
the angle of the mandible on physical examination of the neck, as well as medial
displacement of the lateral pharyngeal wall on endoscopic examination of the laryngopharynx.
Again, airway compromise is a potential complication of parapharyngeal space infections.
Treatment, in addition to appropriate antibiotic coverage, is wide surgical drainage.
B) Viral
Viral infections of the oral cavity and laryngopharynx can cause dysphagia
directly from lesions along the mucosal lining of the upper aerodigestive tract,
or indirectly secondary to cranial nerve damage as a consequence of viral infiltration
of upper cranial nerve ganglia. Herpes virus can cause both of these general categories
of dysphagia. Herpes infections of the hypopharynx and larynx result in extremely
painful mucosal lesions that precipitate dysphagia secondary to intense odynophagia
(32) (101). In these cases systemic antiviral therapy might be indicated.
Patients with Ramsay Hunt syndrome, or herpetic viral infection of the external
auditory canal, can develop significant cranial nerve neuropathy not only involving
the facial nerve, but the glossopharyngeal, vagus and hypoglossal nerves as well
(33) (102). In such instances systemic antiviral therapy is indicated as well
as aggressive supportive measures such as dietary supplementation and airway protection
(34) (103).
C) Fungal
Fungal infections of the oral
cavity, pharynx and esophagus can result in significant dysphagia and odynophagia.
While fungal infections such as those caused by Candida are typically seen in
immunocompromised hosts, immune-competent individuals may develop candidiasis
as well (35) (99). Physical examination is notable for a white, plaque-like exudate,
sometimes with ulceration, on any mucosal surface from the wet line of the lips
to the distal esophagus. Treatment ranges from topical antifungal therapy to systemic
antifungal therapy, depending on the host immune status (36) 100).
D) Acid Reflux
References
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Infectious
& Inflammatory Swallowing Disorders
