Dysphagia (Swallowing Difficulty): Causes, Diagnosis and When to See an ENT

Swallowing is a complex neuromuscular process with three phases: oral preparation (chewing and bolus formation), pharyngeal phase (bolus transit to the pharynx and laryngeal closure), and oesophageal phase (peristaltic movement from oesophagus to stomach). A disorder in any phase causes dysphagia. If laryngeal closure during swallowing is insufficient, aspiration — food or liquid entering the trachea — occurs; this is a leading cause of pneumonia in the elderly.

Neurological causes include stroke (most common), Parkinson's disease, ALS, multiple sclerosis, and brainstem tumours. Structural/mechanical causes: oropharyngeal or oesophageal cancer, Zenker's diverticulum, cricopharyngeal dysfunction, oesophageal stricture, and cervical osteophytes. Functional/motility disorders: achalasia and oesophageal spasm are leading causes of oesophageal dysphagia. Iatrogenic causes: radiotherapy, post-neck surgery fibrosis, and some medications (calcium channel blockers, anticholinergics) can impair swallowing.

Flexible Endoscopic Evaluation of Swallowing (FEES) uses a thin fiberoptic camera placed transnasally into the pharynx to observe swallowing of real foods (coloured jelly, bread, water). Aspiration, penetration, and pharyngeal residue are visualised. Its applicability at the bedside or in intensive care settings makes FEES practical. Video Fluoroscopic Swallowing Study (VFSS, "barium swallow") images the oral, pharyngeal, and oesophageal phases of swallowing in real-time X-ray with barium contrast. Both methods complement each other: FEES better evaluates the oropharyngeal phase, VFSS the oesophageal phase.

Dysphagia treatment is tailored to the underlying cause. Swallowing rehabilitation is managed by a speech-language pathologist (SLP) and covers swallowing manoeuvres (Mendelsohn manoeuvre, head rotation, supraglottic swallow), tongue-pharynx strengthening exercises, and texture modification. The IDDSI classification standardises food textures from thin liquids to purée. For structural or neurological dysphagia, endoscopic balloon dilation, botulinum toxin injection, or cricopharyngeal myotomy are surgical options. In aspirating patients, limiting oral intake and providing enteral nutrition via nasogastric or PEG tube is life-saving.

Radiotherapy in head and neck cancer treatment is the leading cause of chronic dysphagia affecting the oral cavity, pharynx, and laryngeal structures. Xerostomia, mucositis, and fibrosis impair swallowing quality long-term. Pre-radiotherapy swallowing rehabilitation (prophylactic exercise) significantly improves outcomes. Our multidisciplinary tumour council assesses each patient's dysphagia risk before treatment and initiates rehabilitation concurrent with therapy.