John Khoury, Carla LoPinto-Khoury Dysphagia can be either neurological or mechanical. Mechanical dysphagia is more likely to present with problems swallowing solid foods whereas neurological dysphagia is more noticeable with liquids than with solids. Examples of nonneurological causes of dysphagia include obstruction from esophageal carcinoma or oropharyngeal muscle involvement in patients with inflammatory myositis. Neurological causes of dysphagia may include a brainstem lesion or neuromuscular disorders. Although the absence of tongue fasciculations does not rule out a diagnosis of amyotrophic lateral sclerosis (ALS), the presence of tongue fasciculations, especially on a board exam question, is highly specific for ALS. ALS is a motor neuron disease that often presents with dysphagia, weakness, a combination of upper and lower motor neuron signs including brisk reflexes and atrophy, including the tongue. Proximal muscle weakness as opposed to distal weakness is typically seen with disorders of muscle or the neuromuscular junction. For instance, myopathies, myositis, and muscular dystrophies all may present with proximal muscle weakness, and some disorders are associated with ocular involvement as well such as diplopia and ptosis. However, the pattern of waxing and waning would point to a myasthenic syndrome—most commonly myasthenia gravis (MG) or the rarer Lambert-Eaton myasthenic syndrome (LEMS). The most common cause of ptosis is disinsertion of the levator palpebrae superioris tendon from the tarsal plate, which is more common in older patients. It is a benign nonneurological condition unless it interferes with vision, in which case surgery can be performed. Ptosis can be a sign of dysfunction of the third cranial (oculomotor) nerve, which innervates the levator palpebrae; third nerve dysfunction can also cause pupillary dilatation (mydriasis) as well as a “down and out” eye as the actions of the VI and IV cranial nerves are unopposed. A diabetic third nerve palsy will result in ptosis as well as diplopia but should spare the pupil.
A 65-Year-Old Male With Dysphagia
What is your differential diagnosis for dysphagia?
What is the significance of the absence of tongue fasciculations?
With the previous exam, what could the proximal muscle weakness indicate?
What other conditions can you consider with a unilateral ptosis?
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13 A 65-Year-Old Male With Dysphagia
Case 13
