D y s p h a g i a an d S w a l l o w i n g

D i s o rd e r s
a b,
E. Berryhill McCarty, MA , Tiffany N. Chao, MD *

KEYWORDS
 Dysphagia  Swallowing disorders  Aspiration

KEY POINTS
 Dysphagia refers to the impairment of the swallowing mechanism that may result in pene-
tration or aspiration of secretions of food contents into the airway.
 Dysphagia is common in the general population and can be a significant cause of
morbidity and mortality, negatively impacting an individual’s quality of life, nutritional sta-
tus, and overall health; in addition, the health care costs and hospitalization rates associ-
ated with dysphagia and its complications are significant.
 Dysphagia has a variety of causes and is categorized by location (oropharyngeal or
esophageal) and further subcategorized by mechanism (structural or propulsive).
 Assessment and management of dysphagia is dependent on accurate clinical history tak-
ing and can be aided by clinical swallowing evaluations conducted by speech and lan-
guage pathologists.
 Treatment depends on cause but may include swallowing therapy, proton-pump inhibi-
tors, surgery, or in severe cases, permanent bypass of the swallowing mechanism by in-
terventions like nasogastric tubes or percutaneous endoscopic gastrostomy tubes.

INTRODUCTION
Dysphagia and Swallowing Disorders: Definitions
Dysphagia is a symptom of swallowing impairment that can occur if there is a malfunc-
tion with any part of the swallowing mechanism. Dysphagia can reduce quality of life,
can compromise nutrition, and may result in penetration or aspiration of oropharyn-
geal secretions or food contents into the airway, compromising ventilation.1 Penetra-
tion involves passage of material into the larynx, but not beyond the true vocal folds.
When material passes below the true vocal cords and into the trachea, this is termed
aspiration.2 In most healthy individuals, aspiration results in a cough reflex as the body
attempts to prevent the passage of foreign material into the airway.3 When subglottic

a
Department of Otolaryngology, University of Pittsburgh, 203 Lothrop Street #500, Pittsburgh,
PA 15213, USA; b Department of Otolaryngology–Head and Neck Surgery, Hospital of the
University of Pennsylvania, 3737 Market Street, 3rd Floor, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am 105 (2021) 939–954

https://doi.org/10.1016/j.mcna.2021.05.013 medical.theclinics.com
0025-7125/21/ª 2021 Elsevier Inc. All rights reserved.
940 McCarty & Chao

penetration fails to elicit this cough reflex, this is known as silent aspiration.2 Other
important terms that relate to swallowing disorders include aphagia (the inability to
swallow), odynophagia (painful swallowing), and globus sensation or globus pharyng-
eus (the feeling of foreign body sensation).1,2,4,5 Dysphagia can often accompany
these other sensations (or in some cases be caused by them), but it does not always.
Dysphagia is classified by mechanism: structural dysphagia refers to swallowing dif-
ficulty caused by too narrow a lumen or overly large food bolus; propulsive (also
known as motor) dysphagia results from problems with peristalsis or impaired upper
esophageal sphincter (UES) relaxation.1 It is possible for dysphagia to be a mixed
type as well with both structural and propulsive features. Dysphagia is further classi-
fied based on location and which phase of the swallowing mechanism is impacted,
typically oropharyngeal dysphagia or esophageal dysphagia.2,5,6

Prevalence and Cost

Dysphagia is common with approximately 1 million new cases diagnosed annually in
the United States7,8 or 1 in 25 adults, although only a minority seek care for it.9
Although prevalence is dependent on the age of the patient, the cause, and the
method of diagnosis, one report estimated prevalence in the general population
around 20%, and dysphagia seems to occur more frequently in women and older in-
dividuals.9,10 Although this article is aimed at evaluation and management of
dysphagia in adults, it is worthwhile to briefly note its prevalence in the pediatric pop-
ulation: although less prevalent than in the elderly population, dysphagia is still a com-
mon pediatric condition typically resulting from congenital abnormalities like
esophageal atresia, esophageal webbing, and systemic conditions like muscular dys-
trophy. Conditions like cleft palate can prevent proper latching and result in malnutri-
tion and delayed developmental milestones. Although these pediatric conditions are
typically caught and corrected early, some congenital conditions like esophageal
webbing and muscular dystrophy continue to negatively impact patient health into
adulthood.11
Given the natural atrophy of the swallowing muscles and changes in mental alert-
ness that often come with aging, symptoms of dysphagia are especially prevalent in
the elderly. Some studies suggest that up to 60% of nursing home residents experi-
ence dysphagia, and up to half of all Americans over the age of 60 experience
some type of swallowing disorder.12,13 It is a significant cause of mortality, with the
Agency for Health Care Policy and Research reporting more than 60,000 deaths
resulting from swallowing disorder complications.14 Aspiration pneumonia is one of
the most concerning complications and is one of the leading causes of death in the
elderly as well as a significant source of hospital admissions and delayed discharge
in the older population.2,14,15
Other complications of dysphagia include choking, bronchospasm, chronic malnu-
trition and weight loss, muscle wasting, and dehydration.2,15 In surgical patients,
particularly patients with head and neck cancer, dysphagia often results in poor
wound healing and reduced tolerance to treatments, such as radiation and chemo-
therapy.16 It is a primary cause of delayed discharge for patients.17 Given these com-
plications, dysphagia has significant morbidity. The health care costs associated with
the condition and its sequelae are immense. Multiple studies have found that individ-
uals with dysphagia have longer hospital stays, increased rates of hospital readmis-
sion, increased mortality within a year of being admitted to the hospital, and
increased use of health care services overall.2,17–20 One estimate for the cost of
dysphagia to the US health care system is between $4 and $7 billion annually.20
 Dysphagia and Swallowing Disorders 941

This cost estimate does not take into account indirect costs like the economic impact
of patients lost to the workforce as a result of their dysphagic symptoms.20
Beyond the health care costs, there are the costs on emotional and mental well-
being. Even mild symptoms can have a profoundly negative impact on quality of
life.2 Inability to eat properly may result in feelings of isolation and embarrassment dur-
ing social gatherings21; this is in addition to possible chronic discomfort and bad
breath. Many patients with dysphagia report symptoms of depression and inability
to enjoy time with others.22

PHYSIOLOGY OF SWALLOWING

Disruption or impairment of any phase of the swallowing mechanism can result in

symptoms of dysphagia and can result in penetration or aspiration. Swallowing can
be divided into distinct phases, although the oral and preoral anticipatory phases
are often grouped together23:
1. The preoral anticipatory phase. In this phase, sensing food through sight, smell, and
taste involuntarily stimulates saliva production in anticipation of intake. Saliva, via
both mechanical and enzymatic functions, makes chewing and swallowing easier.
2. Oral preparatory phase. The second phase of swallowing is voluntary, controlled by
the cortex and brainstem, and involves the transformation of food into a bolus via
manipulation by the tongue, teeth, and palate. The bolus, a result of food being
masticated and mixed with saliva, is primed for transport to the pharynx.
3. The oral transport phase. In the transport phase, the food bolus is propelled to the
hypopharynx by the tongue. Once it reaches the tonsillar pillars, it triggers the swal-
low reflex. In a healthy individual, the oral phase lasts about 1 second.
4. The pharyngeal phase. This phase is involuntary and initiated by the swallow reflex.
It is further divided into 4 subphases: velopharyngeal closure (prevents bolus regur-
gitation into the nasopharynx), peristaltic contraction of pharyngeal constrictors
(propels the food bolus through the pharynx), laryngeal elevation and closure (pro-
vides airway protection and prevents aspiration), and UES opening (allowing the
bolus to pass from the larynx to esophagus).
5. The esophageal phase. In this final phase, the food bolus passes through the UES
via peristaltic contractions involuntarily elicited in response to the swallow. This
peristalsis clears residue from the pharynx and through the esophagus. When
the food enters the esophagus, the lower esophageal sphincter (LES) relaxes
and remains relaxed as the bolus passes into the stomach via peristalsis.1,2,7,23
Each of these phases can be functionally evaluated to identify which aspect of the
swallowing mechanism is impaired and which will assist in diagnosing the cause of
dysphagia symptoms.
In evaluating this swallowing mechanism and its pathologic conditions, it is useful to
have a general familiarity with the anatomy (Fig. 1) and innervation of the oropharynx
and esophagus as well as an understanding of the mechanism of peristalsis.
The muscles of the oral cavity and mastication are innervated by the trigeminal (V)
and facial (VII) cranial nerves, whereas the pharyngeal muscles are innervated by the
glossopharyngeal (IX) and the vagus (X) cranial nerves.1,23 Innervation of the UES is
more complex. The muscles of the UES, primarily the cricopharyngeal muscle and
the inferior pharyngeal constrictors, are also innervated by the vagus nerve, but the
musculature that facilitates the opening of the UES during swallowing, the suprahyoid
(stylohyoid, digastrics, mylohyoid) and thyrohyoid muscles, are innervated by the V,
VII, and the hypoglossal (XII) cranial nerves.1,23 As a result of the tonic contraction
942 McCarty & Chao

A B

Fig. 1. (A) The musculature of the pharynx and larynx viewed laterally. (B) Sagittal view of
the pharynx and larynx. (Acknowledgements: Graphics created by Merriweather McCarty
and used with her permission.)

of the cricopharyngeal muscle (by CN X), the UES remains closed at rest. Opening of
the UES during swallowing occurs with the relaxation of the cricopharyngeal muscle
(brought on by the cessation of vagal excitation) and the simultaneous contraction
of the geniohyoid muscle (innervated by C1 fibers traveling along XII) and the supra-
hyoid muscles (innervated by V), which pull open the UES and displace the larynx for-
ward and upward.1,23
When the food bolus passes through the UES, it is moved along the esophagus via
peristalsis until it arrives at the LES. Peristaltic contractions elicited in response to the
swallowing mechanism are termed primary peristalsis; they are the sequential inhibi-
tion (called deglutitive inhibition) and contraction of the esophageal constrictors, mov-
ing the bolus down the length of the esophagus.1,24 Secondary peristalsis is initiated
by “bolus-induced distension” of the esophageal wall and can occur anywhere along
its length; it begins at the point of distension and proceeds distally.24 A third type of
contraction that can occur in the esophagus is termed tertiary esophageal contrac-
tions; these are spontaneous, disordered, and nonperistaltic contractions and may
lead to impaired acid clearance resulting in gastroesophageal reflux disease
(GERD).25 LES relaxation occurs from the start of deglutitive inhibition until the
completion of peristaltic contraction, allowing the food bolus to enter the stomach.
At rest, the LES is contracted and closed. The surrounding muscles of the right dia-
phragmatic crus assist act as an external sphincter during inspiration, cough, and
abdominal straining.1,26 Weakness in diaphragmatic function should be considered
as a possible cause or exacerbator of dysphagic symptoms.
Oropharyngeal dysphagia is further separated into 2 categories: oral phase and
pharyngeal phase.2 Oral-phase dysphagia is associated with poor formation of and
control of the food bolus. Oral-phase dysphagia typically results in prolonged retention
in the oral cavity. It can also be accompanied by drooling, food leakage from the
mouth, and difficulty initiating swallowing.7 The oral phase of the swallowing mecha-
nism (under voluntary control) can be impaired by decreased lip closure, decreased
strength in the muscles of mastication, and limited tongue coordination or movement.7
Pharyngeal-phase dysphagia typically results either from poor propulsion of the bolus
by the tongue or via obstruction at the UES. Unlike the oral phase, the pharyngeal
phase is under involuntary control, and impairments here may present as delayed
swallow reflex, decreased velopharyngeal closure resulting in nasal regurgitation,
decreased epiglottic movement and decreased laryngeal elevation on swallowing,
or disorders or injury to the UES.27,28 Depending on the cause of oropharyngeal
 Dysphagia and Swallowing Disorders 943

type, patients may feel globus sensation in the neck or experience nasal regurgitation,
aspiration, and symptoms of reflux.1,27
Less viscous materials (like water and clear liquids) are more likely to be aspirated in
swallowing disorders. Increased substance viscosity slows its transit through the
swallowing pathway.7 Because one of the most common causes of dysphagia is a
delayed initiation of the swallowing reflex, this longer time in transit means a greater
likelihood that the bolus will be correctly transported.7
Esophageal dysphagia can be either structural, propulsive, or mixed in type and can
occur in any portion of the esophagus.13 The esophagus is divided into the cervical
portion (from the pharyngoesophageal junction to the suprasternal notch) and the
thoracic portion (from the suprasternal notch to the diaphragmatic hiatus).1 Esopha-
geal dysphagia symptoms are localized to the neck or chest and can include reflux,
food impaction, and chest pain. It is important to note, however, that localization in
dysphagia is often nonspecific and mixed.6,13 Management of dysphagia is often
dependent on its cause, so accurate diagnosis and understanding of the swallowing
mechanism are essential.

CAUSES

As discussed, dysphagia is typically subclassified by location (oropharyngeal vs

esophageal) and mechanism (structural vs propulsive). Timing of symptoms, whether
they are intermittent or progressive, can help further clarify the cause of swallowing
disorders.1,7,13 Fig. 2 provides a framework for considering the causes of dysphagia.
Although there is a documented decline in swallowing function with normal aging,
more significant symptoms of dysphagia may serve as a herald for further deteriora-
tion in health.2,12,28 Although dysphagia may be caused by a variety of causes, the
2 most common causes result from (1) neurologic or anatomic injury of the cerebral
cortex or brainstem and (2) direct injury or damage to the muscles of swallowing.7
When evaluating patients, it is also important to consider conditions that do not neces-
sarily fit into the framework described above, conditions like chronic obstructive pul-
monary disease (COPD), and other respiratory conditions that affect respiration may

Fig. 2. (A) Algorithm for approaching the differential diagnosis for dysphagia. (B) Condi-
tions in bold represent the most common causes of dysphagia, along with their associated
symptoms and conditions. BMI, ; CVA, cerebrovascular accident.
944 McCarty & Chao

make coordination of respiration and swallowing more difficult and predispose to

swallowing disorders.29

DISCUSSION
Diagnosis: Differential Diagnosis
An algorithm for approaching differential diagnosis for dysphagia based on sympto-
mology is presented in Fig. 2.

Diagnosis: History
Although most causes of dysphagia are benign, symptoms of dysphagia can serve as
an early herald for several malignancies and must be thoroughly evaluated. One of the
most essential tools in this evaluation is a complete and accurate patient history.
Below is a suggested series of questions the generalist should ask to elicit important
information:
1. Where does it feel like you have the most difficulty with swallowing?
 Localization of dysphagia symptoms may point to different causes:
- Globus sensations localized to the suprasternal notch may point to either

oropharyngeal or esophageal dysphagia; more distal dysphagia (esophageal)

is referred proximally w30% of the time.13,30
27,30
- Sensations localized to the chest are esophageal in origin 70% of the time.

2. How long have you had difficulty swallowing? When do you have problems with
swallowing? Is it present all the time or off and on?
 Timing of symptoms is very important in distinguishing between malignancy and
more benign causes of dysphagia:
- Rapidly progressive over the course of weeks to months may indicate malig-

nancy, especially if it is accompanied by weight loss. Slowly progressive with a

background of reflux points toward peptic stricture.30
- Intermittent or episodic dysphagia that has been present for years may indi-

cate a more structural and typically benign process, such as esophageal

web or eosinophilic esophagitis.13,31
3. What types of food or drinks cause swallowing difficulties? Is it primarily with liq-
uids? Solids? Or both?
 This may be the most important sign to elicit from your patient.
- Intermittent dysphagia with solid food only indicates a structural
impairment.32,33
- Constant dysphagia with both solids and liquids indicates a motor

impairment.32,33
4. Do you have any of these other symptoms:
 Dry mouth may contribute to oropharyngeal dysphagia and inability to make a
proper bolus from lack of saliva. This symptom might point to an underlying
medication issue (Table 1) or a systemic problem like Sjogren disease.34
 Leakage or spillage of food or liquids from mouth may indicate a problem in the
oral phase of swallowing, perhaps a cranial nerve injury.33
 Nasal regurgitation indicates oropharyngeal dysphagia and inability to seal off
the nasopharynx, or velopharyngeal insufficiency.33
 Cough, fear of choking with swallowing may indicate impairment with pharyngeal
stage and possible aspiration risk.2
 Vocal changes and hoarseness
- If hoarseness precedes dysphagia, the injury is likely laryngeal and could be a

result of chronic damage due to GERD or laryngopharyngeal reflux (LPR).35

 Dysphagia and Swallowing Disorders 945

Table 1
Common medications that can cause symptoms of dysphagia

Drugs that cause xerostomia (lack of ACEi: Captopril, lisinopril

saliva causes impaired food transport) Antiarrythmics: Disopyramide,
mexiletine, procainamide
Antiemetics: Meclizine, metoclopromide,
ondansetron, prochlorperazine,
promethazine
Antihistamines/decongestants:
chlorpheniramine, cyproheptadine,
diphenyhydramine, hydroxyzine,
pseudoephedrine
Diuretics: Ethacrynic acid SSRIs:
Citalopram, fluoxetine, nefazodone,
paroxetine, sertraline, venlafaxine
TCAs: Amitriptyline, desipramine,
imipramine
Anticholinergic/antimuscarinic drugs Atropine, benztropine mesylate,
(lack of saliva and problems with dicyclomine, hyoscyamine,
smooth muscle function and ipratropium, oxybutynin,
coordination) propantheline, scopolamine,
trihexyphenidyl, tolterodine
Neuromuscular blocking agents Atracurium, cisatracurium, doxacurium,
mivacurium, pancuronium,
pipecuronium, rocuronium,
succinylcholine, tubocurarine,
vecuronium
Local anesthetics Benzocaine, benzonatate, lidocaine
Antipsychotics/neuroleptic medications Chlorpromazine, clozapine,
(pseudo-PD: Tardive dyskinesia can fluphenazine, haloperidol, lithium,
impact patients’ ability to chew or loxapine, olanzapine, quetiapine,
swallow) risperidone, thioridazine, thiothixene,
trifluoperazine
Antineoplastics/immunosuppressants Azathioprine, carmustine, cyclosporine,
(chemotherapy may directly injure daunorubicin, lymphocytic
esophageal mucosa, predispose to viral immunoglobulin, paclitaxel, porfimer,
and fungal infections) vinorelbine
High-dose corticosteroids (skeletal muscle Dexamethasone, methylprednisolone,
wasting, immunocompromise) prednisolone, prednisone
Medications that cause drowsiness or Antiepileptic drugs, benzodiazepines,
confusion narcotics, skeletal muscle relaxants
Medication-induced esophageal injury Doxycycline, Clindamycin, Tetracycline,
(pill esophagitis) Quinidine, aspirin, bisphosphonates,
iron, methylxanthines, NSAIDs, KCl,
ascorbic acid

Adapted from Balzer KM. Drug-induced Dysphagia, Int J MS Care 2(1):40-50, 2000.32

- If hoarseness occurs after dysphagia symptoms have been present, the clini-
cian should be concerned about a compromised recurrent laryngeal nerve,
possibly because of advancing malignancy.1
 Odynophagia or other types of pain on swallowing typically indicates a type of ul-
ceration that could be caused by infection, inflammatory process, malignancy,
mechanical injury, or pill-induced esophagitis.27,30,32
946 McCarty & Chao

 Chest pain may indicate esophageal spasm, achalasia, a peptic stricture if

accompanied by reflux, or, more infrequently, an esophageal adenocarcinoma.30
 Regurgitation between meals or spontaneous regurgitation at night suggests a
dysmotility issue but may also occur with a Zenker or other cervical diverticula.
 Reflux: see Diagnostic Pearl Box 1.
 Weight loss: see Diagnostic Pearl Box 2.
5. What medications are you on?
 A list of dysphagia-causing medications is provided in Table 1. Medication-induced
dysphagia is common and can occur with medications that cause dry mouth,
impact smooth muscle function and coordination (such as anticholinergics and anti-
muscarinics), directly damage mucosa (iron, doxycycline, nonsteroidal anti-
inflammatory drugs [NSAIDs]), cause immunocompromise predisposing to fungal
and viral esophagitis, or result in decreased awareness, mental functioning, or
sensation, especially in the elderly.13,32 Chronic opioid users are also more likely
to present with motor disorders, including esophageal outflow obstruction.13

D i a g n o s t i c P e a r l B o x 1 : g a s t ro e s o p h a g e a l ref l u x d i s e a s e
and laryngopharyngeal reflux
One particularly common diagnosis that may lead to symptoms of dysphagia is GERD. GERD can
be a cause of dysphagia as well as exacerbate the condition. Chronic reflux may result in
anatomic changes, such as strictures, which result in esophageal dysphagia but can also lead
to esophageal dysmotility from a variety of mechanisms, including ineffective peristalsis or
LES relaxation abnormalities.35 Other causes of dysphagia, such as achalasia or anything that
weakens the UES, may result in symptoms of reflux. LPR shares many pathophysiological mech-
anisms as GERD but is considered by otolaryngologists to be a distinct condition. LPR is also an
inflammatory condition, but it affects the upper aerodigestive tract and involves the reflux of
gastroduodenal content, which, like GERD, can result in morphologic changes in these tissues,
some which may result in inflammation and cause dysphagia. Reflux episodes in GERD are typi-
cally liquid, occur in the recumbent position, and occur at night, whereas reflux episodes in LPR
are typically gaseous or less acidic, occur in the upright position, and occur in the day. The 2 may
occur together.36–38 Some studies suggest that LPR may be mediated by factors other than
gastric acid, such as pepsin.39

D i a g n o s t i c P e a r l B o x 2 : We i g h t L o s s a n d Dy sp h a g i a
Dysphagia symptoms alone can certainly cause a significant weight loss, but pa-
tients with dysphagia and significant unexpected weight loss must undergo more thorough
work-up for malignancy. Regardless of cause, significant weight loss warrants immediate eval-
uation.

DIAGNOSIS: RISK FACTORS

In addition to the questions listed above, the general practitioner should also elicit in-
formation about certain risk factors during their history taking. The presence of certain
risk factors may point to 1 cause over another and is useful in diagnosis and
management.
Some important risk factors to consider:
 History of head and neck radiation: results in mucosal injury causing both acute
damage and chronic fibrosis, which can result in oral mucositis and weakened
musculature of swallowing.40
 Dysphagia and Swallowing Disorders 947

 Personal or family history of thyroid issues: severely enlarged thyroid or goiter

may cause compressive symptoms resulting in dysphagia or globus sensation.41
 History of inflammatory bowel disease (IBD) or celiac disease: oral manifesta-
tions and esophageal lesions associated with IBD may cause dysphagia symp-
toms.42 Patients with celiac disease may also present with esophageal webs that
cause dysphagia.43
 History of prolonged intubation, esophageal or head and neck surgery, or inges-
tion of caustic material or pills may predispose to strictures.32,44,45
 History of atopy or allergy may point toward eosinophilic esophagitis.46
 Current use of chemotherapy or diagnosis of an immunocompromised state like
HIV/AIDS should alert the clinician to the possibility of esophagitis owing to
opportunistic infections like Candida, herpes simplex virus, cytomegalovirus
(CMV), or tumors like Kaposi sarcoma or lymphoma.47
 History of recurrent pneumonia or chest infections may indicate presence of si-
lent aspiration.2

DIAGNOSIS: PHYSICAL EXAMINATION

Once a complete patient history has been collected, a targeted physical examination
should be completed. It is important to note here that dysphagia is often only 1 mani-
festation of more systemic disease processes, particularly of muscular dystrophies,
conditions like scleroderma, or other neuromuscular and connective tissue diseases.
In evaluating oropharyngeal dysphagia, clinicians should look for the following signs:
 Neuromuscular conditions: Dysarthria, dysphonia, ptosis, tongue atrophy.33
 Neck: Examine for thyromegaly or other masses; presence of Virchow node in the
left supraclavicular fossa is associated with esophageal cancer.33,40
 Mouth and pharynx: Examine dentition (absent or poor dentition can interfere
with mastication), check for buccal lesions and ulcerations, and look for signs
of opportunistic infection.33
 Skin: Certain rashes may suggest diagnosis of scleroderma or mucocutaneous
conditions that can affect the esophagus.48–50
 Respiratory: Cough, wheezing, desaturations may indicate either current silent
aspiration pneumonia or a respiratory cause like COPD.29
Physical examination is less helpful in evaluating esophageal dysphagia given the
difficulty of examining the larynx and esophagus in the typical general internist’s clinic.
If the physical examination is unrevealing and the patient is suspected of having
esophageal dysphagia, the next recommended step is referral to an otolaryngologist
or gastroenterology for more advanced examination techniques. If a neurologic cause
is suspected, a complete neurologic workup is recommended.

DIAGNOSIS: ADVANCED TECHNIQUES

Details of the history and initial physical examination will guide the next steps in diag-
nosis. More advanced diagnostic procedures can be conducted by gastroenterolo-
gists, radiologists, otolaryngologists, or speech and language pathologists (SLPs)
depending on reported symptoms. An otolaryngologist may perform a flexible fiberop-
tic laryngoscopic examination of the nasopharynx, oropharynx, hypopharynx, and lar-
ynx to assess for masses, mucosal lesions, pooling of secretions, or other structural
issues. If oropharyngeal dysphagia is suspected based on history and physical exam-
ination, the patient should be referred to a health care professional who is trained to
conduct a clinical swallowing examination (CSE), typically an SLP. This test provides
948 McCarty & Chao

additional information about the patient’s cognition, phonation, functionality of the cra-
nial nerves involved in swallowing, speech intelligibility, and cough strength to examine
how well the patient handles secretions. This test also typically assesses swallowing
with foods and liquids of different consistencies.7,33 Following a CSE, a fiberoptic endo-
scopic evaluation of swallowing (FEES) study may be performed. FEES should be used
if there is a concern for silent aspiration or motility issues. It involves the use of a flexible
fiberoptic laryngoscope to visualize the larynx and pharynx and evaluate swallowing
mechanism and management of secretions, typically while the patient swallows
different consistencies of liquids or solids that have been colored with a food dye for
improved visualization of the material.7,28,51 An FEES can be performed at the bedside,
but is limited by a brief “white-out” phase during the swallow itself, precluding direct ex-
amination of the swallowing mechanism. Information is obtained from observation of
pharyngeal sensation and location of the bolus before and after the swallow.
A modified barium swallow study (MBSS), also known as a videofluoroscopic swal-
lowing study, can also be used to evaluate the oral and pharyngeal phases of swallow-
ing and provides dynamic information on the oropharyngeal and pharyngoesophageal
phases of swallowing. Similar to a CSE, in an MBSS, the patient is observed eating a
variety of foods at different consistencies, but unlike a CSE, the food is coated with
barium, and the patient is seated in front of an X-ray or fluoroscopy machine that al-
lows for visualization of the swallowing mechanism and peristalsis. Unlike FEES,
this test allows for real-time visualization of pharyngeal and esophageal muscle
contraction and relaxation and can also detect minute amounts of aspiration or pene-
tration.7,52 In addition, it is possible to measure temporal characteristics of swallowing,
such as transit time. MBSS includes the need for specialized equipment, which re-
quires both a radiologist and an SLP, and like an esophagram, it requires exposure
to radiation, making it unsuitable for pregnant women or multiple re-testings, unlike
FEES.7,52,53 Although an MBSS can detect gross structural abnormalities of the
oropharynx and esophagus, it is designed to provide information on swallowing func-
tion and should not be used as an initial diagnostic tool if a structural cause of
dysphagia is more likely and there is no concern for aspiration.
If esophageal dysphagia is suspected, 2 different procedures are typically used as
an initial diagnostic workup: upper endoscopy (esophagoscopy) and a barium swallow
study (esophagram). In evaluating esophageal dysphagia, flexible esophagoscopy
may be the single most useful procedure. It provides better visualization of mucosal
lesions and masses than an esophagram or MBSS, and it allows for direct mucosal
biopsies.54 In addition, esophagoscopy allows for immediate therapeutic intervention
with esophageal dilation if needed. The more recent emergence of eosinophilic esoph-
agitis as a cause of unexplained dysphagia has led to the recommendation that
mucosal biopsies be routinely obtained even if mucosal lesions are absent.55 Esoph-
agoscopy is typically performed under anesthesia by a gastroenterologist, but some
otolaryngologists are able to perform awake transnasal esophagoscopy in the office.56
An esophagram (barium swallow) evaluates the entire esophagus and can be used
in addition to esophagoscopy for visualization of possible structural causes of
dysphagia. However, a barium swallow should be performed before endoscopy if a
proximal esophageal lesion is suspected or if there is a history or clinical suspicion
for stricture. The patient drinks a barium liquid and is seated in front of an X-ray or fluo-
roscopy machine that allows for visualization of the esophagus during liquid transit. It
only requires a radiologist and can provide additional information about possible
masses, strictures, esophageal dysmotility, and abnormalities like hiatal hernias and
Zenker diverticulum. An esophagram is typically done if the dysphagia is not
adequately explained by endoscopy or additional information is needed.53 Patients
 Dysphagia and Swallowing Disorders 949

Table 2
Diagnostic techniques to evaluate dysphagia

Diagnostic
Technique Description Useful for Disadvantages
CSE Comprehensive Patients with concern Does not provide
bedside evaluation for aspiration or other comprehensive
by SLP functional swallowing structural
disturbances information
FEES Flexible fiberoptic Detection of structural Unable to directly
pharyngolaryngoscopic or sensory view pharyngeal
examination abnormalities structures during
performed while in the oropharynx, active phase of
patient swallows hypopharynx, or swallowing
foods and liquids of larynx; assessment
various consistencies of aspiration or
penetration; can be
performed at bedside
Flexible Flexible fiberoptic Structural evaluation Typically performed
esophagoscopy evaluation of of esophagus, under anesthesia;
esophagus can perform biopsies poor visualization
of pharynx and
region around
UES
Rigid Rigid transoral Structural evaluation Requires general
esophagoscopy evaluation of of pharynx and upper anesthesia, unable
oropharynx, esophagus, can to evaluate distal
hypopharynx, and perform biopsies esophagus in
upper esophagus adults
Esophagram Video fluoroscopic study Structural evaluation of Radiation exposure
(barium used to evaluate esophagus, also
swallow) esophageal contour provides some
and transit of information on
barium liquid or pill esophageal motility
Modified barium Video fluoroscopic Detection of Radiation exposure
swallowing evaluation of dysfunctional
study (MBSS) swallowing performed swallow in oral,
with speech language oropharyngeal, and
pathologist esophageal phases;
gross pharyngeal or
esophageal structural
abnormalities
24-h pH Placement of transnasal Gold standard for Patient discomfort
monitoring flexible catheter to detection of GERD, from presence of
detect reflux events dual channel probes transnasal catheter
may detect LPR, for 24 h
and addition of
impedance probes
may detect nonacid
reflux events
High-resolution Pressure-sensing catheter Detection of esophageal
manometry placed transnasally dysmotility or
abnormalities of UES
and LES
950 McCarty & Chao

with otherwise negative workups on barium swallow and endoscopy may undergo
high-resolution esophageal manometry to determine whether a motility disorder is
present.
Although these diagnostic techniques are perhaps the most commonly used in the
evaluation of dysphagia, there is currently no standardized protocol for dysphagia
screening, and different institutions may follow their own guidelines.57 There are a va-
riety of other diagnostic techniques that may also be used; a brief list and description
of them are included in Table 2.

MANAGEMENT

Treatment of dysphagia is highly dependent on cause. If the dysphagia is part of a sys-

temic condition like a neuromuscular disease or an autoimmune disease, the most
effective management is treatment of the underlying condition. For oropharyngeal
dysphagia resulting from functional deficits, the primary aim in management should
be on educating the patient on how to eat safely and reduce aspiration risk. If a medi-
cation is causing the symptoms, recommendations are to switch medications, and if
that is not possible, then to engage in swallowing therapy. The SLPs serve an impor-
tant role here and can teach patients swallowing exercises and safer positions to eat in
that will protect the lungs; this is particularly useful after cerebrovascular accidents or
other neurologic events. In addition, diet changes are usually recommended after a
CSE, only allowing foods of a certain viscosity. This type of dietary modification has
been shown to reduce risk of aspiration pneumonia. In many cases, the functional
swallowing deficits caused by stroke will resolve over time, but if they do not, then
it may be appropriate to consider a nasogastric tube or gastrostomy with enteral feed-
ings. Non-oral feeding methods should also be considered for progressive neurologic
conditions like amyotrophic lateral sclerosis and Parkinson disease (PD), although
these patients are still at risk of aspirating salivary secretions. Surgical procedures,
such as laryngeal suspension and vocal cord augmentation, may also be used to
reduce aspiration risk.30 Myotomy (diverticulotomy) via open surgical or endoscopic
approach is appropriate for cricopharyngeal bars or Zenker diverticulum.58
Structural esophageal dysphagia resulting from neoplasm or achalasia can also be
surgically managed, or endoscopic dilatation may be done as a palliative measure to
improve quality of life. In the case of strictures or other structural esophageal
dysphagia, endoscopic dilatation via bougie or a balloon dilator is often effective man-
agement; if severe, myotomy is also an option.13 If the cause of esophageal dysphagia
is infection, such as CMV or candida, it is best to treat the underlying infection and
consider antibiotic, antiviral, or antifungal prophylaxis in the case of immunocompro-
mised patients. Eosinophilic esophagitis can be effectively treated by elimination diet
and proton-pump inhibitors (PPI); swallowed topical steroids can be given in severe
cases, and dilation can be used if strictures have developed.59
In almost all cases though, management of dysphagia is multidisciplinary, involving
clinicians, SLPs, and dieticians. Patients should be educated on how to eat safely; diet
should be optimized, and PPIs or other acid suppression medications should be used,
especially in the case of GERD or LPR.13 Empiric dilation in combination with PPI, even
in the absence of stricture or in the presence of mild strictures, is common in clinical
management,60 although other studies dispute such practice.61

SUMMARY

Dysphagia, defined as impairment of the swallowing process, is a common symptom

and is a significant source of morbidity and mortality in the general population. Not
 Dysphagia and Swallowing Disorders 951

only are the health care costs associated with dysphagia and its complications
immense, but also swallowing disorders dramatically alter the quality of life of the un-
fortunate patients who suffer from them, negatively impacting their ability to socialize
with loved ones or enjoy a meal. Dysphagia has a variety of causes, and elucidating
the correct cause is essential in management of the condition. Broadly, dysphagia
can be classified as oropharyngeal or esophageal and structural or propulsive. A multi-
disciplinary approach is typically required for effective diagnosis and treatment and
may involve neurologists, radiologists, otolaryngologists, and SLPs. Treatment is
dependent on cause and ranges from medical management of associated symptoms
to swallowing therapy to surgery. It is a fascinating symptom that demands a clinician
with deft history-taking skills and a thorough knowledge of the pathophysiology of
swallowing.

CLINICS CARE POINTS

 A detailed and complete medical history is the single most important diagnostic tool in the
diagnosis and management of dysphagia. It is necessary for distinguishing oropharyngeal
dysphagia from esophageal dysphagia, a determination that will direct next steps in care.
 Recurrent pneumonias (especially if they are localized to the lower right lobe) may indicate
the presence of silent aspiration and warrant a complete swallowing evaluation.
 Although symptoms of dysphagia alone can cause a significant weight loss, rapid and
unexpected weight loss is an alarm symptom and warrants immediate and thorough
evaluation for possible malignancy.
 Not only are speech and language pathologists helpful in the diagnosis of swallowing
disorders but also they are often essential in the treatment of dysphagia; they train
patients in safe swallowing technique, guide dietary modifications, and continue to be an
active part of a patient’s swallowing therapy. Their role highlights the multidisciplinary
nature in the management and treatment of swallowing disorders.
 The 3 most common and useful advanced techniques in the diagnosis of dysphagia are
fiberoptic endoscopic evaluation of swallowing, modified barium swallow, and
esophagoscopy.
 Management of dysphagia is dependent on cause and may include treatment of an
underlying condition, acid suppression medication, endoscopic dilation of the esophagus,
surgery, diet modification, swallowing therapy, or some combination of these treatments.

DISCLOSURE

The authors have no commercial or financial conflicts to disclose.

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