Difficulty Swallowing


  • Oropharyngeal stage
    • oral phase
      • Prepares the bolus to be swallowable
      • Coordinated contraction of the tongue and striated muscles of mastication (cerebellar output from CNV3, CNVII and CNXII)
      • Can take between 1 and 10 secs depending on the liquidity of bolus
    • Pharyngeal phase
      • Involuntary swallow reflex- important to protect against aspiration
      • Rapid sequence of events
        • Soft palate rises
        • The hyoid bone and larynx move upward and forward
        • The vocal folds move into the midline
        • The epiglottis folds backward to protect the airway
        • The tongue pushes backward and downward on the bolus and the pharyngeal walls move inward from top to bottom, pushing the bolus down the back of the throat
        • The upper oesophageal sphincter relaxes and is pulled open by movement of the hyoid and larynx
        • The pharynx returns to resting
        • Under involuntary control from a number of cranial nerves (primarily CN IX and X)
        • The whole process lasts about a second
  • Oesophageal phase
    • The bolus is propelled down by involuntary peristaltic contractions of the skeletal muscles of the upper oesophagus.
    • The lower oesophageal sphincter relaxes at the initiation of the swallow and persists until the bolus reaches the stomach
    • This lasts up to 20 secs



  • Common (around 7-10% of adults >50 years old are reported to have some form of dysphagia
    • Incidence increases in hospital and nursing homes
  • It is important to take a clear/thorough history to identify whether the patient actually has dysphagia
    • VS Globus VS heartburn
  • Oropharyngeal dysphagia is more common in the elderly and can, but not always, be grouped with a number of other symptoms as part of an identifiable underlying cause (most commonly- stroke)
  • Oesophageal dysphagia is caused by motility disorders or obstruction of the oesophagus by things like strictures/cancer/rings.


  • HPC
    • Duration, severity, progression
      • Is it intermittent (e.g. rings/webs; diffuse oesophageal spasm, nutcracker oesophagus); is it gradually progressive? Does repeated swallowing help? (neuromuscular disorders); Does the valsava manoeuvre help? (obstructive?)
      • Any initiating factor; any provoking factors; any relieving factors?
      • Is the problem
        • at the start of swallow e.g. with choking, coughing, aspiration (oropharyngeal or neuromuscular problem);
        • after swallow e.g. food getting stuck in throat, regurgitation/vomiting
        • gfgfgf
        • ddx
    • Any associated symptoms?
      • Pain (more likely in neuromuscular causes)
      • Change in appetite or ability to eat
        • Important to ask about weight loss
        • Ask about other red flags e.g. night sweats, fatigue
      • Ask about heartburn
      • Any regurgitation?
      • Any coughing/aspiration, any hallitosis (Zenker’s diverticulum)
      • Any hoarseness, problems with speech, hiccups
  • PMHx
    • GORD, heartburn, diabetes, scleroderma
    • Ask about medications:
      • mnmn
  • Ask about other Social History (Alcohol and smoking in particular); Family History; ICE etc


  • If necessary, it may be appropriate to measure the patient’s level of consciousness and cognition/mental status.
  • Examination of the cranial nerves
    • In particular, sensory and motor function i.e. CN V, VII-XII (including gag function)
  • Observe and palpate the neck, and assess whilst swallowing (may be useful to try water swallow)
  • Examine, as much as possible, the oral cavity (if nasopharyngoscopy is possible, this can be used also)
  • You may also want to do a cerebellar examination and assess motor, sensory and deep tendon reflexes elsewhere in the body if there is suspicion of a CNS problem.
  • Assess weight, nutrition status etc if appropriate.
  • Assess chest for signs of aspiration too.


  • Almost all patients should have endoscopy to look for any obvious structural abnormalities (NB normal endoscopy doesn’t rule out structure abnormality)
  • Barium swallows are also commonly used in patients with dysphagia.
  • Manometry is useful in patients who have a history suggestive of a motility disorder or in whom no abnormality has been found with endoscopy/barium studies

Differential Diagnosis

  • Oropharyngeal
    • Neuromuscular
      • Disease of the CNS e.g. TIA/Stroke; Parkinson’s; Brainstem tumours; Degenerative diseases: e.g. ALS/MND; MS; Huntington’s
      • Postinfectious: Poliomyelitis; Syphilis
      • Peripheral neuropathy
      • Myaesthenia Gravis
      • Dermatomyositis
      • Muscular dystrophy
    • Obstructive
      • Tumours
      • Inflammatory masses
      • Trauma/surgery
      • Zenker’s Diverticulum
      • Oesophageal Webs
  • Oesophageal
    • Neuromuscular disorders
      • Achalasia
      • Spastic motor disorders
        • Diffuse Oesophageal Spasm
        • Nutcracker oesophagus
        • Hypertensive LOS
      • Scleroderma
    • Obstructive lesions
      • Intrinsic
        • Tumours
        • Strictures
          • Peptic
          • Radiation-; chemical-; medication-induced
        • Lower oesophageal rings (Schatzki’s rings)
        • Oesophageal Webs
        • Foreign Bodies
      • Extrinsic
        • Vascular compressions
        • Mediastinal masses
        • Other cancers

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