Swallowing difficulties

Red Flags

Progressive dysphagia
Weight loss
Haematemesis
Otalgia
Neck lump
Voice change
Risk factors (Smoking, alcohol consumption, previous malignancy or radiotherapy)

Assessment and recognition

History

Duration (acute or chronic)
Progression (worsening, intermittent, improving)
Trigger (e.g. after eating meat)
Regurgitation of food
Gurgling sound in the neck and halitosis - suggests pharyngeal pouch
Location of ‘sticking point’
Sore throat or pain when swallowing (odynophagia)
Ability to tolerate liquids or solids
Change to speech or voice
Coughing when eating (aspiration risk)
Reflux symptoms (related with stricture and globus sensation)
Taste
Previous surgery or radiotherapy to upper airway or oesophagus
Previous gastroscopy
Smoking and alcohol status

Examination

Oral examination: ability to open mouth (trismus), dentition, tongue coating (white coating – candida or xerostomia), erythematous or exudate covered tonsils
Neck: movement (inability to move neck is torticollis), lymphadenopathy or masses, skin changes

Differentials of swallowing difficulties:

Sore throat

Dysphagia may occur due to a severe sore throat. See links for information about tonsillitis, peritonsillar abscess (quinsy) and supraglottitis.

Soft food bolus

Typically presents to ED. A typical patient will present after eating a meal, most commonly containing meat, with discomfort and complete inability to swallow saliva. Many soft food boluses pass spontaneously. Patients are referred to either ENT or gastroenterology urgently. In hospital medical management aims to relax the oesophageal musculature with agents such as glucagon and buscopan. Patients undergo flexible or rigid oesophagoscopy if the bolus does not pass. Recurrent food bolus obstruction should trigger referral to gastroenterology. Read here for further info.

Pharyngeal/oesophageal foreign body

Typically presents to ED. There is usually a clear history of ingestion of a hard/sharp foreign body such as a fish or meat bone, a denture, or another object. If there is any history of battery ingestion then this is particularly urgent, as the battery can erode through tissue quickly. Ingested foreign bodies causing severe pain and dysphagia need to be urgently referred to ENT via ED.

Neurogenic dysphagia

Impairment of any phase of the swallowing mechanism causes poor swallowing initiation, drooling, coughing on eating and drinking, nasal regurgitation, aspiration and food remaining in the throat. The history is quite different from a patient with obstructive dysphagia. The gold standard investigation is videofluoroscopy. If neurogenic dysphagia is suspected, referral to a neurologist and speech and language specialist is required. Click here for more info.

Achalasia

Failure of smooth muscle relaxation in the oesophagus and lower oesophageal sphincter causes dysphagia, regurgitation and chest discomfort. Barium swallow is able to demonstrate the lack of normal oesophageal peristalsis.

Pharyngeal pouch

A pouch of pharyngeal mucosa develops via a dehiscence in the fibres of the upper oesophageal sphincter. Small pouches are asymptomatic, but larger pouches can cause dysphagia, regurgitation of undigested food, aspiration and halitosis (bad breath). Patients should be referred to either ENT or gastroenterology, and will have a barium swallow to confirm the diagnosis. The pouch can be surgically excised or the intervening muscle split and stapled via an endoscopic approach.

Globus sensation

This is the sensation of a lump in the throat, sometimes associated with a tight-feeling swallow, but without regurgitation or other red flag symptoms. There are many potential causes of globus, the most common being laryngopharyngeal reflux and anxiety. Investigation is aimed at ruling out malignancy. Click here for further info

Laryngopharyngeal reflux

This is a very common condition where stomach contents (namely activated pepsin enzyme) pass from the stomach to the larynx. Patients present with throat clearing, hoarseness, coughing and a lump sensation in their throat. Symptoms commonly are worse at night or early in the morning after lying down. Management is with diet and lifestyle advice (healthy diet, avoid alcohol and smoking, avoid eating late at night, sleep propped up, exercise and weight loss) and medications (e.g. Gaviscon Advance 10 ml QDS). Click here for more info

Referral Pathways

Same day

Foreign body ingestion causing dysphagia (food bolus) or a battery

Cancer-wait referral

Cases suspicious of upper aerodigestive malignancy

Routine referral

Patient with globus sensation not responding to reflux treatment with no red flag symptoms

Swallowing difficulties

Red Flags

Assessment and recognition

Differentials of swallowing difficulties:

Referral Pathways

Further Reading

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