Neuromuscular disorders typically result in misdirection of the bolus, with repeated swallowing attempts. Liquids, especially at the extremes of temperature, are generally more difficult to handle than solids. Symptoms are often intermittent in nature. Cerebrovascular accident (CVA) is the most common cause in this category. Oropharyngeal muscle weakness is often the mechanism, though there can be poor function of the UES as well. Polymyositis and dermatomyositis are the second most common causes of transfer dysphagia in this category.
Achalasia is a dysmotility disorder of unknown cause and the most common motility disorder producing dysphagia. Impaired swallowing-induced relaxation of the LES is noted, along with the absence of esophageal peristalsis. Most patients present between 20 and 40 years of age. Achalasia may be associated with esophageal spasm and chest pain and with odynophagia. Associated symptoms can include regurgitation and weight loss. Dilatation of the esophagus can be massive enough to impinge on the trachea and cause airway symptoms.11 Therapy involves decreasing the LES pressure by oral medications, the endoscopic injection of botulinum toxin into the muscle of the sphincter, dilatations, or surgical myotomy.
"Nutcracker esophagus" is a motility disorder in which there are high-amplitude, long-duration peristaltic contractions in the distal esophagus. Manometric criteria require readings of >180 mmHg. The cause of nutcracker esophagus is unknown and the prevalence of this disease is debated in the literature. 12 Patients with this disorder frequently have associated psychiatric disorders and about one-third have GERD.
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