Do I see an ENT (Ear, Nose, and Throat) specialist for dysphagia?

Management of Dysphagia: When to Refer to ENT

Yes, you should see an ENT specialist for trouble swallowing (dysphagia), particularly if you have symptoms suggesting oropharyngeal dysphagia such as coughing, choking, or difficulty initiating swallowing. 1

Types of Dysphagia and Appropriate Referrals

Dysphagia is broadly categorized into two types, which determine the appropriate specialist referral:

1. Oropharyngeal Dysphagia:

   • Symptoms: Difficulty initiating swallowing, coughing, choking during meals, nasal regurgitation, wet voice after swallowing, drooling
   • Initial Referral: Speech-Language Pathologist (SLP) for evaluation 1, 2
   • Secondary Referral: ENT specialist for endoscopic evaluation 1, 3

2. Esophageal Dysphagia:

   • Symptoms: Sensation of food getting stuck after swallowing, chest discomfort
   • Referral: Gastroenterologist for endoscopy 1, 4

When ENT Evaluation is Specifically Indicated

ENT referral is particularly important when:

• You experience coughing or choking while eating/drinking 1
• You have unexplained weight loss with swallowing difficulties 1
• You develop recurrent respiratory infections or pneumonia 1, 2
• You have a history of head and neck cancer 1
• You have a hoarse voice or voice changes with swallowing 1
• You have a sensation of food stuck in the throat 1

Diagnostic Approach After ENT Referral

The ENT specialist will typically perform:

1. Fiber-optic Endoscopic Evaluation of Swallowing (FEES):

   • Can be performed in the office setting
   • Allows direct visualization of the pharynx and larynx 1, 2
   • High sensitivity for detecting aspiration

2. Referral for Videofluoroscopic Swallow Evaluation (VSE):

   • Gold standard for evaluating swallowing function 1, 2
   • Performed in conjunction with a speech-language pathologist
   • Assesses all phases of swallowing with different food consistencies 1

Warning Signs Requiring Urgent Evaluation

Seek immediate medical attention if you experience:

• Inability to swallow liquids or saliva 1
• Significant weight loss due to eating difficulties 2
• Signs of aspiration pneumonia (fever, productive cough, chest pain) 1
• Progressive worsening of swallowing function 2

Common Pitfalls to Avoid

• Delayed referral: Many patients with dysphagia delay seeking care, which can lead to malnutrition, dehydration, and aspiration pneumonia 1, 4
• Assuming location of symptoms equals location of problem: Distal esophageal problems can cause symptoms felt in the throat 4
• Missing silent aspiration: Up to 55% of patients who aspirate do not cough (silent aspiration), making clinical assessment alone insufficient 1
• Overlooking neurological causes: Stroke, Parkinson's disease, and other neurological conditions are common causes of dysphagia that require specialized evaluation 5

Conclusion

If you're experiencing trouble swallowing, particularly with symptoms like coughing, choking, or difficulty initiating swallowing, an ENT specialist is an appropriate healthcare provider to see. They can perform specialized evaluations and work collaboratively with speech-language pathologists to develop an effective management plan that reduces your risk of complications like aspiration pneumonia and malnutrition 1, 2.