What is the cause of sudden pain when swallowing and how should it be treated?

Sudden Pain When Swallowing: Causes and Management

Sudden-onset painful swallowing (odynophagia) requires immediate evaluation to exclude life-threatening conditions including esophageal perforation, foreign body impaction, retropharyngeal abscess, or acute stroke, with imaging and endoscopy as first-line diagnostic tools depending on clinical presentation. 1, 2

Immediate Life-Threatening Causes to Exclude

Foreign Body Impaction

• Sharp objects, batteries, or complete esophageal obstruction require emergent endoscopy within 2-6 hours due to risk of perforation (up to 35% with sharp objects), pressure necrosis from batteries, and aspiration risk 1
• Plain radiographs (neck, chest, abdomen) should be obtained first for radiopaque objects, though false-negative rates reach 47% for food bolus and up to 85% for fish bones 1
• CT scan is essential if plain films are negative but clinical suspicion remains high, with 90-100% sensitivity for bone fragments versus 32% for X-ray 1
• Contrast swallow studies should be avoided as they delay intervention and increase aspiration risk 1

Esophageal Perforation

• Look for fever, cervical subcutaneous emphysema, erythema, and neck tenderness on physical examination 1, 2
• CT scan of neck, chest, and abdomen is mandatory when perforation is suspected to identify complications requiring surgical intervention 1
• Obtain CBC, CRP, blood gas analysis for base excess, and lactate levels 1

Acute Stroke Presentation

• Sudden-onset dysphagia to both solids and liquids simultaneously in elderly patients should trigger immediate stroke evaluation 3
• Keep patient NPO until formal swallowing assessment is completed, as 55% of stroke patients have silent aspiration without protective cough 3
• Obtain urgent neuroimaging (CT or MRI brain) even with unremarkable general exam 3

Other Emergent Conditions

• Retropharyngeal or prevertebral abscess presents with odynophagia, fever, and neck pain 2
• Aortic dissection can cause referred esophageal pain 2
• Pneumomediastinum with subcutaneous emphysema causes painful swallowing 2

Non-Emergent Causes of Painful Swallowing

Infectious/Inflammatory Esophagitis

• Peptic esophagitis from GERD affects 8-19% of adults with endoscopic findings 4
• Eosinophilic esophagitis occurs in up to 17% of certain populations 4
• Medication-induced esophagitis (particularly from bisphosphonates, NSAIDs, antibiotics) 4

Radiation or Chemotherapy-Induced Mucositis

• Graded by NCI CTCAE: Grade 3 = severe pain interfering with oral intake 1
• Patient-controlled analgesia with morphine is recommended for severe mucositis pain 1
• Topical anesthetics provide short-term relief on an empiric basis 1

Musculoskeletal Causes

• Longus colli tendinitis with paravertebral calcification causes neck pain and odynophagia 2
• Thyroid cartilage fracture or thyrohyoid ligament syndrome 2
• Pain worsened by palpation, breathing, turning, or twisting argues against cardiac/esophageal pathology 1

Diagnostic Algorithm

Step 1: Immediate Risk Stratification

• If patient reports choking episode, inability to swallow saliva, or known foreign body ingestion → emergent endoscopy within 2-6 hours 1
• If fever + neck swelling/emphysema → CT scan immediately for perforation/abscess 1, 2
• If acute onset with both solid and liquid dysphagia in elderly → stroke protocol with urgent neuroimaging 3

Step 2: Initial Imaging Based on Presentation

• Plain radiographs (biplanar neck, chest, abdomen) for suspected foreign body 1
• CT scan if plain films negative but high clinical suspicion, or if any signs of complications 1
• Avoid contrast swallow studies in acute setting with complete obstruction 1

Step 3: Endoscopic Evaluation

• Emergent flexible endoscopy (within 2-6 hours) for sharp objects, batteries, magnets, or complete obstruction 1
• Urgent endoscopy (within 24 hours) for other esophageal foreign bodies without complete obstruction 1
• Gentle push technique into stomach is preferred for food bolus impaction (90% success rate) 1

Step 4: Swallowing Assessment if Neurologic Cause Suspected

• Videofluoroscopic swallow study (modified barium swallow) or fiberoptic endoscopic evaluation of swallowing (FEES) to assess aspiration risk 3, 5
• Keep patient NPO until formal evaluation completed 3

Treatment Approach

For Mucositis-Related Pain

• Multidisciplinary oral care protocols with saline mouth rinses 4-6 times daily 1
• Patient-controlled analgesia with morphine for severe pain (Grade 3-4 mucositis) 1
• Topical anesthetics for short-term relief 1
• Avoid alcohol-based mouth rinses 1
• Early enteral nutrition if swallowing problems develop 1

For Foreign Body Impaction

• Endoscopic removal is first-line treatment with push technique preferred for food bolus 1
• General anesthesia with endotracheal intubation often required for airway protection 1

For Inflammatory Conditions

• Treat underlying cause (GERD, eosinophilic esophagitis, infection) 4
• Review and discontinue offending medications if medication-induced 4

Critical Pitfalls to Avoid

• Never delay endoscopy or CT imaging for contrast swallow studies in acute presentations 1
• Do not assume absence of cough means no aspiration—55% of aspirators have silent aspiration 3
• Plain radiographs miss up to 85% of fish bones and food bolus impactions—proceed to CT if clinical suspicion high 1
• Anticholinergic medications worsen dysphagia through multiple mechanisms—review medication list 4
• Age-related changes alone do not cause clinically significant painful swallowing—always investigate for pathology 1

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