Dysphagia resident survival guide

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Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Synonyms and keywords: Approach to dysphagia, Dysphagia algorithm, Dysphagia workup, Dysphagia management, Dysphagia diagnostic approach

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Dysphagia is defined as "difficulty swallowing." It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach. According to the International Classification of Diseases (ICD-10) which is endorsed by the WHO, dysphagia is a symptom rather than a disease. Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Dysphagia is distinguished from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. The endoscopy for esophageal dysphagia should be performed when the patient presented with symptoms of difficulty swallowing, painful swallowing, and aspiration. This is the standard test performed when the patient has a risk of developing pneumonia and diagnosing swallowing difficulties. Videofluoroscopic swallowing study is performed for oropharyngeal dysphagia. It provides information about delay in initiation of pharyngeal swallowing, nasopharyngeal regurgitation, residue of ingested food within the pharyngeal cavity after swallowing, and aspiration of ingested food. The cornerstone of any dysphagia evaluation is a detailed history and a thorough review of symptoms that can differentiate esophageal from oropharyngeal dysphagia and help predict the specific etiology of dysphagia with an accuracy of approximately 80% confirmed by specific testing. How a patient describes his or her difficulty and its timing, associated symptoms, and other characterizations may specifically denote the anatomic level of swallowing dysfunction.


Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of dysphagia.

Common Causes

Depending upon the type of dysphagia, the causes can be categorized into two subsections:[1][2][3][4][5][6]

Common Causes of Oropharyngeal Dysphagia

Common causes of oropharyngeal dysphagia
Neuromuscular disorders Mechanical and obstructive causes Medication side effects Others
Medications that reduce salivary flow:

Common Causes of Esophageal Dysphagia

The common causes of esophageal dysphagia can be divided into four categories.[7][8][9][10][11]

Structural (Mechanical) disorders Motor disorders Esophageal tumors Systemic diseases Miscellaneous
Intrinsic compression Extrinsic Compression Primary Secondary
Mucosal rings and webs Strictures: Vascular compression:

Less Common Causes

Less common causes of dysphagia include:

To review a complete list of dysphagia causes, click here


Patient with Dysphagia
Difficulty in initiating a swallow
associated with cough, choking
or nasal regurgitation
Dysphagia to solids and liquids, or solids,
sensation of food stuck in esophagus
(seconds after initiating swallow)
Oropharyngeal dysphagia
Esophageal dysphagia

Shown below is an algorithm summarizing the diagnosis of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]

History and Physical examination
Identify alternate diagnoses such as xerostomia, globus, esophageal dysphagia
Laboratory findings and CNS imaging
Identify syndromes with specific treatment such as myasthenia gravis, toxic and metabolic myopathies, CNS tumors
No systemic disease identified
Neuromuscular disorders without specific treatment
Nasoendoscopy (to evaluate for structural causes of dysphagia)
Videofluoroscopic swallowing +/-manometry (to characterise severity and mechanism of swallow dysfunction)
Structural lesions with specific therapy such as zenker's diverticulum, orophayngeal tumors
Severe dysfunction or risk of aspiration pneumonia necessitating the institution of nonoral feeding, tracheostomy
Dysphagia ammendable to cricophayngeal myotomy
Dysphagia ammendable to specific therapy (diet modification, swallow therapy +/- temporary nonoral feeding)

Shown below is an algorithm summarizing the diagnosis of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]

Dysphagia to solids and liquids
Dysphagia to solids (may progress to liquids)
Motility disorders
Mechanical obstruction
Chronic heartburn
Regurgitation and/or respiratory symptoms
Chronic heartburn
Elderly (>50 years), weight loss, anemia
Primary motility disorders
Secondary motility disorders
Foreign body
Esophageal or cardia carcinomas
Endoscopy (+/-esophageal biopsy)
Barium Swallow indicated when:
Endoscopy findings are normal
❑ Endoscopy is contraindicated due to:
❑ History of surgery for esophageal/laryngeal cancer
❑ History of radiation
Caustic injury
❑ Complex stricture
❑ Risk of perforation
Endoscopy access is limited


Shown below is an algorithm summarizing the treatment of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.[1][4][2]

Systemic disease with specific therapy
such as myasthenia gravis, myopathies,
parkinson's disease, infections and others
Treat the underlying disease
CNS tumors and oropharyngeal tumors
Surgical resection, chemotherapy or radiotherapy
Oropharyngeal dysphagia
Structural disorders such as cervical webs
and rings, zenker's diverticulum and others
Treatment of the disorder
Medication side effects
Discontinue medication
Severe dysfunction and
risk of aspiration pneumonia
❑ Non-oral feeding
Neuromuscular disorder without specific therapy such as stroke, dengerative diseases and others
Cricopharynegal dysfunction
Cricopharyngeal myotomy
Swallowing maneuvers and postural techniques
❑ Dietary modification
❑ Temporary non-oral feeding

Shown below is an algorithm summarizing the management of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.[1][6]

Esophageal dysphagia
Age>50 years, weight loss,
anemia and other alarm
signs and symptoms
Endoscopy +/- other imaging studies
Surgical resection or
chemotherapyof the detected
esophageal carcinoma
GERD symptoms
Proton pump inhibitor trial for 4 weeks
Dysphagia unresolved
Structural or inflammatory
lesions detected on endoscopy
and/or barium swallow
Treat the detected lesions
Esophageal manometry
Treat the
detected motility disorders


  • Evaluate for drugs causing decreased salivary flow or those causing esophageal mucosal injury.
  • Treat underlying disorders first.



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