What is the initial workup for a patient presenting with dysphagia (difficulty swallowing) in an Ear, Nose, and Throat (ENT) setting?

Dysphagia Workup in ENT Setting

Initial Clinical Assessment

Begin with a detailed history focusing on whether dysphagia is oropharyngeal versus esophageal, as this distinction determines the entire diagnostic pathway and is critical for ENT evaluation. 1, 2

Key History Elements to Elicit

• Timing and initiation: Difficulty initiating swallowing, coughing/choking during meals, nasal regurgitation, or food dribbling suggests oropharyngeal dysphagia 2, 3
• Frequency pattern: Daily versus intermittent symptoms, and whether occurring with solids, liquids, or both 4
• Associated symptoms: Timing of coughing, choking, regurgitation, speech changes, or sensation of food stopping in the chest 4, 3
• High-risk conditions: Screen specifically for stroke, Parkinson disease, dementia, ALS (present in 48-86% of ALS patients), prior neck/c-spine surgery, or radiation therapy 5, 1, 2
• Aspiration history: Patient or family report of coughing with eating/drinking (sensitivity 38-74%, specificity 74-80% for aspiration) 5
• Red flags: Inability to tolerate sufficient liquid diet, profound weight loss, dehydration, or malnutrition warrant urgent evaluation 5, 1

Critical Pitfall to Avoid

Do not rely on symptom location alone—obstructive symptoms perceived in the throat or neck may actually originate from distal esophageal lesions, so the entire esophagus must be evaluated even when symptoms seem pharyngeal. 1, 2, 3

Diagnostic Testing Algorithm

For Oropharyngeal Dysphagia (ENT-Relevant)

Modified barium swallow (videofluoroscopic swallowing study) with speech therapist is the primary diagnostic test, identifying causes in up to 76% of patients and detecting silent aspiration in 55% of aspirators who lack protective cough reflex. 2, 6

• This study assesses oral and pharyngeal phases, laryngeal penetration, aspiration risk, and rehabilitation strategy effectiveness 2
• Fiberoptic endoscopic evaluation of swallowing (FEES) is preferred for post-stroke patients or known neurologic conditions where aspiration is suspected 6
• Flexible laryngoscopy (utilized in 71% of tertiary swallowing center cases) with or without endoscopic swallow evaluation 7

For Unexplained or Mixed Dysphagia

A combined examination with videofluoroscopy plus complete esophageal and gastric cardia evaluation provides higher diagnostic value than either study alone, as distal abnormalities frequently cause referred pharyngeal symptoms. 2, 6

• Biphasic barium esophagram has 96% sensitivity for structural abnormalities and 80-89% sensitivity for motility disorders 1, 2
• This technique includes full-column views, mucosal relief views, double-contrast views, and evaluation from pharynx through gastric cardia 2

When to Refer for Esophageal Evaluation

If symptoms suggest esophageal origin (sensation of food stopping in chest) or if oropharyngeal workup is negative, refer for esophagogastroduodenoscopy (EGD) with esophageal biopsies at two levels, which has >75% diagnostic yield. 1, 2

• Obtain biopsies even if mucosa appears normal to rule out eosinophilic esophagitis 1
• High-resolution manometry should follow if EGD is negative and symptoms persist (98% sensitivity, 96% specificity for achalasia) 1, 2

Management Based on Findings

Immediate Actions for High-Risk Patients

• Maintain NPO status until formal swallowing evaluation if aspiration risk is identified 6
• Screen for swallowing deficits immediately before allowing any oral intake using validated screening tools 6
• Implement oral hygiene protocols to reduce aspiration pneumonia risk 6

Referral Pathways

• Refer to speech-language pathologist for detailed bedside assessment and individualized therapy/dietary modifications 6
• Consider early tube feeding via nasogastric route if dysphagia prevents safe oral intake 6
• Urgent endoscopy within 2-6 hours for complete esophageal obstruction with inability to swallow saliva (avoid oral contrast due to aspiration risk) 6

Common ENT-Specific Causes

The most common causes identified in tertiary swallowing centers are reflux (27%), postirradiation dysphagia (14%), and cricopharyngeus muscle dysfunction (11%), with 13% remaining undetermined despite full workup 7. Neurologic disorders (stroke, Parkinson disease, dementia, ALS) are the most frequent causes of oropharyngeal dysphagia 1, 8, 3.