Diagnostic Approach to Dysphagia

Case: You’re seeing a 65-year-old male in clinic with difficulty swallowing for three months.

What is dysphagia? It is a subjective sensation of difficulty swallowing (1). Patients describe this concern in various ways: “hard time swallowing” “food gets stuck” “full sensation in my throat” “coughing” “choking.” 

Tip: Clarify whether your patient is having difficulty swallowing or painful swallowing (odynophagia) – or both. Painful swallowing will steer you down a different pathway. Sudden onset dysphagia immediately after food ingestion is a medical emergency (1).

Diagnostic Approach to Dysphagia

For non-acute dysphagia, how can we organize our differential diagnosis? I like to use the mechanisms framework: what 3 mechanisms are implicated in dysphagia?

1. Oral and pharyngeal mechanisms (oropharyngeal)

2. Esophageal mechanisms

3. Neurologic/neuromuscular mechanisms

Some dysphagia presentations will have mixed presentations (e.g. a neuromuscular disease impacts the oropharyngeal phase of swallowing) (1, 2).

BOTTOM LINE: 3 mechanisms of dysphagia: oropharyngeal, esophageal, and neurological.

1) Oral and pharyngeal phases of swallowing (Oropharyngeal)

The oral phase of swallowing consists of chewing and the tongue pushing food to the back of the throat. The pharyngeal phase consists of food passing from the back of the tongue down to the esophagus (2). Check out a good visual of the oropharyngeal phase of swallowing here (3).

Oropharyngeal dysphagia = difficulty initiating a swallow.

Causes: structural lesions (e.g. head and neck tumours, prior head and neck radiation, Zenker diverticulum, extrinsic compression (e.g. thyroid mass/goiter, cervical osteophyte) (2, 4).

BOTTOM LINE:

1. Oropharyngeal = dysphagia with solids immediately after swallowing

2. Esophageal = dysphagia with solids several seconds after swallowing

3. Neurologic = dysphagia with solids and liquids, can be a mixed presentation with other neurologic signs and symptoms

2) Esophageal phase of swallowing

Food passes the upper esophageal sphincter down into the esophagus via peristalsis (5).

Esophageal dysphagia = after the initial swallow.

Causes: esophageal stricture, peptic stricture, malignancy, eosinophilic esophagitis, esophageal webs and rings, motility disorders (e.g. achalasia) (1, 2).

3) Neurologic/Neuromuscular

A neurological etiology can affect the oropharyngeal and/or esophageal phases of swallowing. Recall our cranial nerves that are involved in swallowing (for example, the hypoglossal cranial nerve innervates the extrinsic and intrinsic muscles of the tongue, the muscles of mastication are innervated by the trigeminal nerve in the V3 distribution, etc.).

Neurologic/neuromuscular = can present with difficulty initiating a swallow and/or dysphagia after swallowing.

Causes to consider (3 major buckets): neurodegenerative disease (e.g. Parkinson disease, ALS, MS, Alzheimer’s dementia) and muscular/neuromuscular disease (myasthenia gravis, muscular dystrophies), and peripheral/central nervous system (stroke, head trauma, cranial nerve palsies) (4).

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HISTORY & PHYSICAL EXAM TIPS

Ask 5 key initial questions:

1. Is the dysphagia constant or intermittent?

2. Is it acute or chronic?

3. Is it with solids or liquids, or both?

4. Is it sudden or gradual?

5. Is it getting worse?

Physical:

• Head and neck exam

• Abdominal exam if concerns on history

• Neurologic exam if concerns on history

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Back to the case: he reports intermittent difficulty swallowing with solid foods only, which has not progressed. He has the sensation of regurgitation and food feeling “stuck” several seconds after he eats. He denies any unintentional weight loss, hematemesis, or cough. His past medical history is significant for gastroesophageal reflux disease for 10 years. He has been taking a proton pump inhibitor for reflux for several years. Family history is insignificant. On physical exam there is no palpable neck mass or lymphadenopathy, normal cranial nerve exam, and normal head and neck exam.

What diagnostic testing, if any, will we consider?

Diagnostic Testing for Dysphagia

Back to the case: We have a 65-year-old male with suspected esophageal dysphagia (solids feel stuck several seconds after eating), with no progressive symptoms or red flags. An upper endoscopy or barium swallow are the diagnostic tests of choice.

When to refer?

For diagnostic clarification and/or treatment recommendations.

• GI referral for esophageal dysphagia

• ENT referral for oropharyngeal dysphagia

• Neurology referral if concern for underlying neurologic or neuromuscular disease

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Key Take Home Points:

1. Differentiate between oropharyngeal, esophageal, and neurological/neuromuscular dysphagia presentations with a good history and physical exam.

2. Oropharyngeal dysphagia test of choice: modified barium swallow.

3. Esophageal dysphagia test of choice: barium swallow OR upper endoscopy (if barium swallow reveals a lesion, mass, stricture, or concern for malignancy, an upper endoscopy completes the work up).  

4. For a palpable neck mass on exam, ultrasound is the initial diagnostic imaging test of choice.

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References

1. Up to date: Fass R. Approach to the evaluation of dysphagia in adults. In: UpToDate, Eidt Talley, NJ, Robson, KM (Ed), Wolters Kluwer. Accessed June 22, 2024).

2. Chilukuri P, Odufalu F, Hachem C. Dysphagia. Mo Med. 2018 May-Jun;115(3):206-210. PMID: 30228723; PMCID: PMC6140149.

3. Spieker MR. Evaluating dysphagia. Am Fam Physician. 2000 Jun 15;61(12):3639-48. PMID: 10892635.

4. Shaker R. Oropharyngeal Dysphagia. Gastroenterol Hepatol (N Y). 2006 Sep;2(9):633-634. PMID: 28316533; PMCID: PMC5350575.

5. Panara K, Ramezanpour Ahangar E, Padalia D. Physiology, Swallowing. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541071/

6. Martin-Harris B, Canon CL, Bonilha HS, Murray J, Davidson K, Lefton-Greif MA. Best Practices in Modified Barium Swallow Studies. Am J Speech Lang Pathol. 2020 Jul 10;29(2S):1078-1093. doi: 10.1044/2020_AJSLP-19-00189. Epub 2020 Jul 10. PMID: 32650657; PMCID: PMC7844340.

7. Chen A, Tafti D, Tuma F. Barium Swallow. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493176/

8. 8 Canadian Association of Radiologists. Canada. 2021-2022 [June 2024]. Available from https://car.ca/wp-content/uploads/Head-and-neck.pdf