Difficulty Swallowing (Dysphagia)

Dysphagia refers to difficulty swallowing. It may occur at any stage of the swallowing process and is broadly divided into oropharyngeal (difficulty initiating a swallow) and oesophageal (obstruction or motility problems lower down). Recognising the cause is crucial, as it ranges from benign to malignant disease.

👄 Oropharyngeal Dysphagia

Difficulty initiating a swallow due to problems in the mouth, pharynx, or upper oesophagus.

• Causes: Neurological disorders (stroke, Parkinson’s, MS), structural lesions (Zenker’s diverticulum, pharyngeal tumours), neuromuscular disease (myasthenia gravis), radiation therapy.
• Symptoms: Coughing, choking, nasal regurgitation, aspiration, difficulty controlling bolus.

🫁 Oesophageal Dysphagia

Impaired passage of food/liquid down the oesophagus after initiation of swallowing.

• Causes:
  • Mechanical: stricture, carcinoma, Schatzki’s ring, oesophageal webs.
  • Motility: achalasia, diffuse oesophageal spasm, scleroderma.
  • Inflammatory/Other: GERD, eosinophilic oesophagitis.
• Symptoms: Food “sticking” in throat/chest, regurgitation, chest pain, heartburn.

🔎 Clinical Approach

🗣️ History

• Onset & duration: Acute, subacute, chronic.
• Food type: Solids → liquids (mechanical); both from start (motility).
• Associated symptoms: Weight loss, odynophagia, cough, aspiration, reflux.
• Neuro features: Weakness, slurred speech, cranial nerve involvement.
• Past history: GERD, Barrett’s, surgery, radiotherapy.

🧑‍⚕️ Examination

• 👄 Oral/Pharyngeal: Structural lesions, poor coordination, thrush.
• 🧠 Neurological: Cranial nerve palsies, signs of stroke, Parkinsonism.
• 📉 General: Nutritional status, dehydration, weight loss.

🧪 Diagnostic Tests

• 📷 Barium swallow: Outlines strictures, rings, motility problems.
• 🔬 Upper endoscopy (OGD): Direct visualisation + biopsy.
• 📈 Oesophageal manometry: Gold standard for achalasia/motility disorders.
• 🎥 Videofluoroscopic swallow (VFSS): Best for oropharyngeal phase & aspiration.
• 💧 pH monitoring: For reflux-related dysphagia.

🛠️ Management

👄 Oropharyngeal Dysphagia

• 🗣️ Speech & swallow therapy: Especially post-stroke.
• 🥣 Dietary modification: Thickened fluids, pureed diets to reduce aspiration.
• 🩺 Medical/surgical: Treat tumours, infections, structural lesions (e.g., cricopharyngeal myotomy).

🫁 Oesophageal Dysphagia

• 🪢 Mechanical: Endoscopic dilation, stenting, or surgery for strictures/tumours.
• ⚡ Motility: Calcium-channel blockers/nitrates for spasm; Botox injection or Heller myotomy for achalasia.
• 🔥 Reflux/Inflammatory: PPIs for GERD, diet modification, fundoplication if refractory.

⚠️ Complications

• 🫁 Aspiration pneumonia: Common in neurological disease.
• 📉 Malnutrition & dehydration: Secondary to poor intake.
• 🪢 Oesophageal stricture: From chronic reflux or caustic injury.

👩‍⚕️ Referral

• 🔬 Gastroenterology: For endoscopy, dilation, motility testing.
• 🗣️ Speech & Language Therapy: For oropharyngeal phase problems.
• 🧠 Neurology: If underlying neurodegenerative disease suspected.
• 🔪 Surgery/ENT: For tumours, Zenker’s diverticulum, or refractory achalasia.

✅ Take-Home Messages

• Always distinguish between oropharyngeal and oesophageal dysphagia.
• Red flags: Progressive dysphagia, weight loss, odynophagia, haematemesis → urgent OGD (2-week wait in UK for suspected cancer).
• Multidisciplinary care is often required (gastroenterology, neurology, speech therapy, dietetics).