History and physical examination are extremely important for the diagnosis of dysphagia. Common related symptoms are (i) choking and coughing, (ii) eating meals more slowly, (iii) throat clearance during or after meals, (iv) feeling of food stuck in the mid-chest or the throat, (v) frequent pulmonary infections, (vi) weight loss, (v) changes in diet consistency of food, preference to liquids and semisolids, and (vi) neurological changes.[28]

Physical signs include (i) loss of dentition, (ii) abnormal lip closure, (iii) vocal changes, and (iv) neurological changes.

Oropharyngeal dysphagia should be differentiated from esophageal dysphagia. Each should be considered as a distinct group.

The presence of one or more of these symptoms can predict oropharyngeal dysphagia: (i) A delay in oropharyngeal initiation of swallowing, (ii) deglutitive cough, (iii) nasal aspiration during swallowing, and (iv) There is a need for the repetitive swallow to clear the nasal secretion.[29]

Patients with oropharyngeal dysphagia should be considered for a barium swallow. They should also be referred to a neurologist, otolaryngologist, and speech pathologist for further assessment.

Dysphagia can be of acute onset as in stroke. However, in most other conditions causing dysphagia, the symptoms are slowly progressive. Patients who find difficulty to swallow solid food usually suffer from obstruction such as esophageal web, ring, or stricture. Patients who struggle to drink liquids are more likely to have dysphagia due to neurological lesions.

In patients with clinical evidence of nasopharyngeal regurgitation and oropharyngeal dysphagia, the initial test may be a clinical swallow evaluation performed by a speech pathologist. However, this test has its limitations and may miss over 50% of patients with significant aspiration, as seen in videofluoroscopy.[30]

The second test recommended in these patients is a modified barium swallow, which aims at assessing the degree of dysphagia and aspiration.

Patients with signs suggestive of malignancy such as weight loss, bleeding, and oropharyngeal dysphagia should undergo head and neck evaluation and a laryngoscopic examination of the pharynx and larynx, particularly look at (i) oropharynx and (ii) Zenker diverticulum. Zenker diverticulum is typically diagnosed by esophagogram.

Other investigations that may be used for the assessment of these patients are (i) fiberoptic endoscopic evaluation of swallowing (FEES) [31], and (ii) computed tomography of the head and neck and the chest to rule out malignancy.

Fiberoptic endoscopic evaluation of swallowing and video-fluoroscopic swallowing study are both considered to be the gold standard for evaluation of Parkinson’s Disease-related dysphagia. In addition, high-resolution manometry may be a helpful tool.[32]

Patients with no supra-esophageal symptoms and negatively modified barium swallow, negative FEES findings, and clinical evidence of esophageal dysphagia should be referred to a gastroenterologist for a barium video-esophagogram. This assessment should cover both the anatomy (strictures or tumor) and motility function of the esophagus (such as achalasia). Esophagoscopy is mandatory in patients suspected to have achalasia to exclude pseudo-achalasia or other forms of esophageal obstruction. Endoscopic findings such as esophageal dilatation and retention of food are not diagnostic of achalasia.

A barium esophagogram is relatively simple and of low cost and is considered the first line of investigation of esophageal dysphagia.[33] Timed-barium esophagogram is helpful in the diagnosis of achalasia. It can help in objectively document treatment outcomes and early detect recurrence.[34]

Other investigations recommended in patients with esophageal dysphagia are (i) esophagogastroduodenoscopy (EGD), which can help in the diagnosis of esophagitis, webs, rings, esophageal strictures, and tumors, (ii) esophageal manometry, which is usually needed in patients with chronic dysphagia, and (iii) high-resolution esophageal manometry is helpful in the diagnosis of achalasia (the presence of incomplete relaxation of the esophagogastric junction together with the absence of organized peristalsis is consistent with the diagnosis of achalasia).[35]

Based on high-resolution esophageal manometry, there are three subtypes of achalasia can be identified- type I: characterized by low intra-esophageal pressure (classic achalasia), type II: characterized by pan-esophageal pressurization, and type III: characterized by high-amplitude spastic contractions. Identifying the subtype of achalasia can guide the choice of therapy.[36]

Oropharyngeal dysphagia associated with myasthenia gravis responds to treatment with anticholinesterase inhibitors. 

A speech therapist usually sees patients with oropharyngeal dysphagia. The management plan may include (i) elimination of certain food consistencies from the diet. (ii) adjustment of meal bolus seizes and (iii) use of techniques such as chin-tuck, head-turn, and supraglottic maneuvers to help in minimizing/preventing aspiration. Also, strengthening and coordinating muscles involved in swallowing. Gastroscopy tube may be indicated in patients who fail to respond to the above-stated measures.[1] 

Most patients with stroke will regain their swallowing function within 1 to 2 weeks after infarction. 

In patients with advanced Parkinson disease, dysphagia does not respond to the dopamine precursor L-DOPA treatment. Measures discussed earlier should be applied.

Patients with Zenker diverticulum are usually managed surgically by cricopharyngeal myotomy through the oral route. However, if the patients have mild symptoms, dilatation of the upper esophageal sphincter may be indicated.[37] 

Patients with dysphagia related to head and neck tumors will require long-term swallow rehabilitation. Usually, their dysphagia continues despite the surgical excision of the tumor mass, radiation therapy, or chemotherapy.[38]

Patients with a mild esophageal stricture are usually managed by controlling their esophageal reflux and by endoscopic esophageal dilatation. 

Dysphagia caused by esophageal malignancies is usually esophageal adenocarcinoma secondary to longstanding reflux disease. In these patients, the development of Barrett metaplasia and dysplasia is a precursor to cancer. Esophageal squamous carcinoma typically occurs in the upper-mid esophagus and is related to smoking and alcohol drinking. Patients with esophageal malignancy are usually managed by a team of surgeons, gastroenterologists, and radiation oncologists, and the rehabilitation team.[39]

Patients with achalasia are treated with (i) pharmacotherapy-nitrates, calcium-channel blockers (e.g., nifedipine 10 to 20 mg sublingual 15 to 30 minutes before meals). It acts by lowering the lower esophageal sphincter resting pressure. Side effects include hypotension, headache, dizziness in about one-third of patients, (ii) botulinum toxin A is usually used by direct injection in 4 to 8 quadrants into the lower esophageal sphincter during endoscopy.[40] More than 80% of patients have a clinical response. However, remission occurs within one year in 60% of patients, (iii) pneumatic dilatation- this involves tears of the lower esophageal sphincter using air-filled balloons under fluoroscopic guidance. However, nearly one-third of patients have a recurrence of their symptoms in 4 to 6 years. Pneumatic dilatation is contraindicated in patients with poor cardiopulmonary status or have comorbidities that prevent surgical intervention should esophageal rupture occurs, and surgical intervention needed, and (iv) laparoscopic Heller myotomy – surgical myotomy of the distal esophageal muscle and lower esophageal sphincter. Laparoscopic Heller myotomy, when combined with fundoplication, results in a significant reduction of reflux.[41] The surgery is safe, with a reported mortality of 0.1%. The main complication is perforation of the esophagus or gastric mucosa, and (v) Peroral-endoscopic myotomy (POEM).[42] This procedure involves a high-definition upper endoscope. POEM takes approximately two to three hours, and patients have to stay in the hospital for two to three days for monitoring and to receive intravenous antibiotics.[43]

Based on the high-resolution esophageal manometry results, three subtypes of achalasia can be identified. The identification of the subtype forms the basis of achalasia treatment. These are organized as follows: types I and II: pneumatic dilatation, laparoscopic Heller myotomy, or POEM. For type III: POEM is the preferred treatment.[42][44] 

Because the etiology of dysphagia due to diffuse esophageal spasm (DES) is unknown, and usually patients present with a range of different manifestations and pathology, the treatment of these patients is directed at the symptoms rather than cause treatment.[45] Drugs such as concentrated peppermint oil, nitrates, phosphodiesterase-5 inhibitors, calcium channel blockers, and tricyclic anti-depressants may be used. Other treatments, such as peroral endoscopic myotomy, botulinum toxin, and esophageal dilatation, may be considered.

Scleroderma can cause aperistalsis or low-amplitude esophageal contractions of the distal esophagus as well as a hypotensive lower esophageal sphincter. Usually, these patients have dysphagia to both solids and liquids. The treatment is focused on symptomatic management. No pharmacological intervention has been shown to be promising. Prokinetic agents (metoclopramide, erythromycin, bethanechol, buspirone, and domperidone), which stimulate gut peristalsis, may help.[46] Non-pharmacological approaches, such as acupuncture stimulation.[47] Also, transcutaneous electrical nerve stimulation (TENS) may be indicated in the management of advanced cases.

• Diffuse esophageal spasm.
• Esophageal cancer.
• Eosinophilic esophagitis[48]
• Hiatal hernia.
• Parkinson disease.
• Zenker diverticulum.
• Multiple sclerosis.
• Paterson-Kelly syndrome.
• Dysphagia lusoria is a type dysphagia that develops in childhood, due to compression of the esophagus by vascular abnormality. Usually, there is an aberrant right subclavian artery arising from the left side of the aortic arch, or a double aortic arch, or other rare anomalies.
• Benign strictures.
• Esophageal webs and rings
• Esophageal reflux[49]

• Social isolation because of cough, embarrassment, and difficulties in swallowing
• Pulmonary complications due to chronic aspiration, particularly pneumonia
• Life-threatening complications (dehydration, malnutrition, pulmonary complications, death)
• Reduced quality of life
• Reduced rehabilitation after injury or illness[50]

Oropharyngeal dysphagia should be differentiated from esophageal dysphagia. Each should be considered as a distinct category. While medical history and clinical examination are essential for making such a differentiation, investigations are helpful in identifying the underlying cause under each of these two categories.

The majority of patients with dysphagia may present to the general practitioner or the emergency department. The public, nurses, pharmacists, and patients should be educated about dysphagia. At schools, students with severe disabilities, or orthopedic impairments may require help because of dysphagia. In essence, the school support team in such schools may need a speech-language pathologist with adequate training in swallowing evaluation and management. No one should provide such services without proper official up-to-date training in this area—a team of speech therapists, neurologists, otolaryngologists, oncologists, dietitians, and nurses usually manage patients with oropharyngeal dysphagia. Surgeons, gastroenterologists, radiation oncologists, and rehabilitation team usually manage patients with esophageal malignancy.