Dysphagia refers to difficulty in swallowing solids, liquids, or both, due to impairment in the swallowing mechanism. It can be constant or intermittent and is usually classified based on the phase of swallowing affected (oral, pharyngeal, or esophageal). Dysphagia may lead to malnutrition, dehydration, aspiration pneumonia, and impaired quality of life.

Pathophysiology

Swallowing is a complex process involving sensory input, cranial nerves (V, VII, IX, X, XII), brainstem centers, and coordinated muscle action. Dysphagia results from disruption at any of these levels:

• Oral/Pharyngeal phase – impaired bolus formation or transfer (neurological, muscular, structural).

• Esophageal phase – impaired peristalsis or obstruction (motility disorders, tumors, strictures).

• Systemic/secondary causes – toxins, inflammation, autoimmune diseases.

Signs and Symptoms

• Difficulty initiating or completing swallowing

• Choking, coughing, nasal regurgitation

• Sensation of food “sticking” in throat or chest

• Drooling or pooling of secretions

• Hoarseness, dysarthria, dysphonia

• Chest pain or heartburn (with esophageal pathology)

• Weight loss, malnutrition, dehydration

• Aspiration (recurrent pneumonia, wheezing, stridor)

Clinical Assessment

History

• Onset: acute vs gradual

• Duration and progression (intermittent, progressive, or constant)

• Type of food affected: solids, liquids, or both

• Associated symptoms: odynophagia, regurgitation, aspiration, weight loss, chest pain, cough, voice changes

• Exposures: caustic ingestion, radiation, toxins, medications

• Neurological symptoms: weakness, diplopia, dysarthria, sensory deficits

• Past history: stroke, surgery, systemic disease

Physical Examination

• General: nutritional status, hydration, vital signs

• Head and neck: oral cavity, tonsils, tongue, mucosa, masses or lesions

• Cranial nerves: gag, cough, and swallowing reflexes

• Speech assessment: hoarseness, nasal or breathy voice

• Neurological exam: motor/sensory deficits, reflexes

• Airway signs: stridor, respiratory distress

Investigations

• Endoscopy (EGD) – visualization of obstruction, inflammation, tumors

• Barium swallow (esophagography) – outline of strictures, diverticula, motility

• Esophageal manometry – peristalsis and sphincter function

• pH monitoring – reflux esophagitis

• Imaging – CT/MRI for extrinsic compression, tumors

• Videofluoroscopic swallow study – oropharyngeal dysphagia

• Laboratory tests – CBC (anemia, infection), autoimmune markers

Medical Causes of Dysphagia

The following are the medical causes of dyspgagia, the detailed description is on the table 1

• Neurological: Stroke, ALS, Parkinson’s disease, Myasthenia gravis, Bulbar palsy, Multiple sclerosis

• Structural/Obstructive: Esophageal cancer, strictures, diverticula, foreign bodies, oral cavity/laryngeal tumors

• Motility disorders: Achalasia, esophageal spasm, scleroderma

• Inflammatory/Infective: Esophagitis (reflux, candida, caustic injury), tonsillitis, epiglottitis, peritonsillar abscess

• Systemic/Toxic: Lead poisoning, rabies, tetanus, SLE

• Post-procedural: Radiation therapy, prolonged intubation, tracheostomy

Table 1: Medical Causes of Dysphagia

Differential Diagnosis

• Odynophagia (painful swallowing without true dysphagia)

• Globus pharyngeus (sensation of lump without dysphagia)

• Xerostomia (dry mouth causing difficulty but not obstruction)

• Severe GERD without structural obstruction

• Psychogenic swallowing disorders

Pediatric Considerations

• Physiological: immature swallow reflex in neonates

• Pathological:

  • Congenital anomalies – esophageal atresia, cleft palate, annular stenosis

  • Infections – epiglottitis, stomatitis, pharyngitis

  • Obstructions – foreign body, corrosive ingestion

• Red flags: drooling + stridor + fever → possible epiglottitis (emergency)

Special clinical considerations

• Emergency interventions:

  • If acute airway obstruction suspected → abdominal thrusts, oxygen, prepare for intubation.

• Aspiration risk:

  • Upright position, chin-tuck technique, swallow multiple times before next bite, separate solids from liquids.

• Nutritional support:

  • Modify diet textures, avoid sticky foods, consult dietitian, consider tube feeding if severe.

• Rehabilitation:

  • Swallowing therapy, speech therapy, facial muscle exercises.

Patient education & Counseling

• Explain underlying cause and management plan.

• Teach safe swallowing techniques and posture during feeding.

• Recommend dietary adjustments (soft/moist foods, avoid sticky or dry foods).

• Emphasize oral hygiene and hydration.

• Counsel on aspiration risk and when to seek urgent care (sudden dyspnea, stridor, recurrent choking).

References

1. Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011;469:658–65.

2. Siska PA, Ponnappan RK, Hohl JB, Lee JY, Kang JD, Donaldson WF 3rd. Dysphagia after anterior cervical spine surgery: a prospective study using the swallowing-quality of life questionnaire and analysis of patient comorbidities. Spine. 2011;36:1387–91.

3. Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed; 1999.

4. Kahrilas PJ, Pandolfino JE. Dysphagia. In: Goldman L, Schafer AI, editors. Goldman-Cecil Medicine. 25th ed. Philadelphia: Elsevier; 2016. p. 840–7.

5. Ertekin C, Aydogdu I. Neurophysiology of swallowing. Clin Neurophysiol. 2003;114(12):2226–44.

6. Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology. 1999;116(2):455–78.