What is the best course of action for a patient presenting with neck pain and dysphagia (difficulty swallowing)?

Urgent Evaluation for Malignancy or Structural Pathology is the Priority

A patient presenting with neck pain and dysphagia requires immediate evaluation to rule out head and neck cancer, esophageal malignancy, or other serious structural pathology before considering benign causes. This combination of symptoms demands urgent diagnostic workup, as dysphagia with associated neck pain can represent cancer recurrence, new malignancy, or life-threatening complications. 1, 2

Immediate Red Flag Assessment

The combination of neck pain with dysphagia is a critical warning sign that requires urgent evaluation for:

• Head and neck cancer (primary or recurrent), which commonly presents with both symptoms and requires immediate referral to oncology or ENT 1
• Esophageal or gastroesophageal junction malignancy, which has 96% sensitivity on biphasic esophagram but requires tissue diagnosis 2, 3
• Cervical spine pathology with esophageal compression from anterior osteophytes, disc herniation, or post-surgical complications 4, 5
• Acute infectious or inflammatory processes including retropharyngeal abscess, prevertebral abscess, or longus colli tendinitis 5

Diagnostic Algorithm

Step 1: Determine Urgency Based on Alarm Features

Proceed immediately to urgent endoscopy if ANY of the following are present: 2, 6, 7

• Progressive dysphagia (worsening over weeks to months)
• Weight loss >10% of body weight
• Odynophagia (painful swallowing)
• Age >55 years with new-onset dysphagia
• Inability to tolerate sufficient liquid diet
• History of head and neck cancer or radiation therapy 1

Step 2: Initial Diagnostic Testing

For patients with alarm features: 2, 6

• Esophagogastroduodenoscopy (EGD) with esophageal biopsies is the first-line test, with diagnostic yield >75% 2, 3
• Obtain biopsies at two levels even if mucosa appears normal to rule out eosinophilic esophagitis 2
• CT neck and chest should be obtained concurrently if cervical spine pathology, abscess, or head/neck malignancy is suspected 1, 5

For patients without alarm features but persistent symptoms: 2, 3

• Biphasic barium esophagram can be used as initial test with 96% sensitivity for cancer and 95% for strictures 2, 3
• This allows triage to determine need for endoscopy and evaluates both structural and functional abnormalities 1, 2

Step 3: Distinguish Oropharyngeal vs Esophageal Dysphagia

Critical history questions to guide workup: 6, 7

• Difficulty initiating swallowing, coughing, or choking suggests oropharyngeal dysphagia requiring modified barium swallow and speech-language pathology referral 1, 3, 6
• Sensation of food sticking after swallowing suggests esophageal dysphagia requiring EGD 6, 7
• Solids only progressing to liquids indicates mechanical obstruction (malignancy, stricture) 6
• Both solids and liquids from onset suggests motility disorder 6

Critical pitfall: Obstructive symptoms perceived in the throat or neck may actually originate from distal esophageal lesions—always evaluate the entire esophagus and gastric cardia 2, 7

Specific Cervical Spine Considerations

If cervical spine pathology is suspected based on neck pain characteristics: 4, 5

• Cervicogenic dysphagia can result from degenerative disc disease, anterior osteophytes, facet joint dysfunction, or post-surgical changes 4
• Longus colli tendinitis presents with acute neck pain, odynophagia, and prevertebral calcification on imaging 5
• Post-operative complications after anterior cervical spine surgery require single-contrast esophagram with water-soluble contrast to evaluate for leak 1

Head and Neck Cancer Survivorship Context

For patients with history of head and neck cancer: 1

• Any sudden onset of dysphagia or neck pain should prompt immediate evaluation for recurrence 1
• Refer to experienced speech-language pathologist for instrumental evaluation (videofluoroscopy) to assess for stricture, aspiration, or physiologic dysphagia 1
• Videofluoroscopy is first-line test for suspected stricture due to high degree of coexisting physiologic dysphagia 1
• Refer to gastroenterologist or head/neck surgeon for esophageal dilation if stricture confirmed 1

Management of Functional Dysphagia (Only After Exclusion of Organic Disease)

Functional dysphagia should only be considered after thorough exclusion of structural pathology: 1

• Positive features include inability to swallow without drooling/excessive secretions, or ability to spit saliva but not swallow 1
• Globus pharyngeus (lump sensation) is distinct from true dysphagia and improves with eating 1
• 20% of patients with functional dysphagia experience globus sensation 1

Critical Pitfalls to Avoid

• Never assume benign musculoskeletal cause without imaging and endoscopic evaluation—malignancy must be excluded first 1, 2, 5
• Do not skip esophageal biopsies during endoscopy even if mucosa appears normal, as eosinophilic esophagitis can present without visible changes 2
• Silent aspiration occurs in 55% of patients who aspirate without protective cough reflex, making clinical diagnosis unreliable 2, 6
• Referred pain from distal esophageal or gastric cardia lesions can cause perceived dysphagia in the throat or pharynx 2, 7