Dysphagia

Question 1: What can the patient swallow?

Fluids and small amounts of soft diet without choking - unless very frail, these patients do not need admission and should be managed as urgent outpatients
Very little, sometimes with coughing and spluttering on swallowing - admit these patients for swallowing assessment and enteral/parenteral nutrition; if the patient is coughing or choking on every swallow, consider nil by mouth

Question 2: How long has it been going on for and are they otherwise unwell?

Quick onset dysphagia with pain and infective symptoms implies tonsillitis etc.
Quick onset dysphagia with neurological symptoms implies a cerebrovascular ischaemic event
Gradual onset over weeks or months may signify malignancy (oropharynx, hypopharynx or oeosophagus), especially in the presence of rapid weight loss, smoking history and alcohol consumption
Long term (months to years) and relatively slowly progressing dysphagia may indicate more benign (but no less disruptive) pathology such as pharyngeal pouch in the older patient, a chronic neurological disorder etc.

Question 3: Are they getting lots of chest infections?

Recurrent chest infections in the presence of dysphagia would suggest aspiration - patients should be asked to be nil by mouth pending further assessment; institute a feeding regime

Question 4: Is the dysphagia due to anatomical obstruction or neurological dysfunction?

Take a thorough history, perform a full clinical examination and request blood tests such as U&E; ask for a speech and language assessment; consider the need for a chest radiograph, barium swallow, ultrasound-guided FNA of any neck mass or an MRI scan of the head and neck
If anatomical (ie benign or malignant stricture, pouch, abscess... ) then refer for an ENT opinion
If functional (ie stroke, achalasia... ) then refer for a neurological or gastroenterological opinion

Page last reviewed: 1 December 2022