**4. Differential diagnosis of swallowing disorders**

Dysphagia is a symptom of numerous organic and functional disorders. Impaired swallowing can be high (oropharyngeal) or low (esophageal). Organic dysphagia is characterized by permanent dysphagia (stricture, tumor). Functional dysphagia is that one caused by motility disorders (usually spasms) and has the character of intermittent problems. With these distinct characteristics, patient's history is important in terms of a major or single base diagnosis. The causes of dysphagia are varied and numerous.

Obstructive swallowing disorders: Esophageal tumor, extramural compression, congenital abnormalities (stenosis, atresia), inflammation, trauma (burns, scars, foreign bodies).

Swallowing Disorders Related to Vertebrogenic Dysfunctions 179

other symptoms (Nansel & Szalazak, 1995). The musculoskeletal system can cause problems

We refer to viscerovertebral syndromes when there are primary defects in the visceral organ which can cause segment changes and changes in the functional state of the axial organ. The internal organ problems may cause changes, such as changes in muscle tone, tendons, fascia, subcutaneous tissue, and skin. Often it is difficult to establish a differential diagnosis that distinguishes the primary cause, and inaccurate or erroneous treatment could be the

1. The spinal column (motion segment) is causing symptoms that are mistaken for visceral

2. Visceral disease is causing symptoms that are interpreted as a lesion in some part of the

3. Visceral disease is producing changes in the locomotor system, such as movement

4. A disturbance in the motion segment is triggering visceral disease or (more likely) is

The first two points highlight the necessity for precise differential diagnosis and the problems associated with this. The spinal column with its motion segments can in fact produce symptoms that may mimic symptoms arising in the viscera. If such symptoms stem from the motor system, it is not surprising that drug treatment aimed at organic visceral disease fails. This causes frustration in many patients as the true cause of symptoms is not

If the mechanism causing visceral dysfunction is disturbed function of the motor system, better understanding of this would be of great practical interest, as more effective treatment by the technique of musculoskeletal (manual) medicine would be more widely applied.

Point 2 is the warning that pain perceived in the locomotor system may be a deceptive sign masking serious underlying visceral disease. This suspicion is strengthened if the symptoms of spinal segmental disturbance tend to relapse repeatedly without obvious cause. While the

Point 3 is of major theoretical significance and demonstrates that visceral disease is actually one of the possible causes of dysfunction in the motion segment. Clinical experience teaches that certain visceral diseases are associated with characteristic patterns in the locomotor system. They are so specific that their recurrence is in all probability predictive of a

Point 4 it would seem justifiable to assume that lesion in a motion segment of the spinal column may impair function in the corresponding internal organs. This is borne out by the vasomotor response in the whole segment to which pain is referred. In such cases we can see the disorder clearing up as soon as we treat the motion segment. Reactions of this kind have been noted particularly in connection with the cervicocranial syndrome, especially at the craniocervical junction, including disturbances of equilibrium. Similar phenomena have been observed in connection with certain cardiac arrhythmias. A motion segment dysfunction may activate latent disease in an internal organ. Multiple pathogenic factors

error in point 1 is more common, that in point 2 is all the more fraught with danger.

that mimic symptoms of visceral organ disorder.

In very broad terms, the four possibilities should be envisaged:

activating already latent visceral symptoms (hypothetical).

recognized (Nansel & Szalazak, 1995; Hülse, 1991).

recurrence of the visceral disease.

consequence.

disease.

locomotor system.

restriction, etc.

Non-obstructive swallowing disorders: Neuromuscular diseases (pseudobulbar syndrome, bulbar syndrome, lower motor neuron dysfunction, neuromuscular disorders, muscle disease), autoimmune disease, achalasia, idiopathic spastic dysphagia, psychogenic and functional disorders.

The most common types of non-obstructive swallowing disorders are:


Sometimes, globus pharyngicus (hystericus) is classified as a functional swallowing disorders. Patients describe sensation of a lump in the throat with a characteristic absence of dysphagia. The food does not stick in the throat and fluids pass freely when swallowing, this condition can alleviate symptoms. Some studies suggest an increase in upper esophageal sphincter pressure or abnormal mobility of the hypopharynx. The occurence of these problems is usually associated with psychosocial factors, especially depression and anxiety. Medical treatment usually does not bring relief, although patients may benefit from psychotherapy.
