What are the causes of acute dysphagia in the context of Ear, Nose, and Throat (ENT)?

Causes of Acute Dysphagia in ENT Context

Acute dysphagia in the ENT setting is most commonly caused by foreign body impaction, acute infectious/inflammatory conditions (epiglottitis, tonsillitis, peritonsillar abscess), and trauma, with foreign body impaction being the most frequent emergency presentation requiring immediate assessment for airway compromise and perforation risk. 1

Foreign Body Impaction

Foreign body impaction is the leading cause of acute dysphagia presenting to ENT, accounting for over 100,000 cases annually in the USA alone. 1

• Typical presentation: Acute onset of dysphagia or complete inability to swallow saliva, odynophagia, neck tenderness, retrosternal pain, foreign body sensation, retching, vomiting, and drooling 1
• High-risk objects: Coins and batteries in children; food boluses (especially meat), fish/chicken bones in adults; intentional ingestion in psychiatric patients or prisoners 1
• Anatomical impaction sites: Hypopharynx and upper thoracic esophagus at the cricopharyngeus muscle and aortic arch level 1
• Emergency signs requiring immediate intervention: Choking, stridor, dyspnea (airway obstruction), fever, cervical subcutaneous emphysema, or cervical erythema/tenderness (perforation) 1, 2

Acute Infectious and Inflammatory Conditions

Acute Epiglottitis

• Presentation: Acute painful dysphagia, sore throat, sensation of foreign body in throat, with or without respiratory symptoms 3, 4
• Critical point: Any patient with acute, painful dysphagia requires indirect laryngoscopy to rule out epiglottitis, as this can be a sudden life-threatening condition 3, 4
• Management: Intravenous steroids, antibiotics, humidified oxygen, with mandatory physician observation during first 4 hours; tracheostomy indicated in progressive disease 4

Tonsillitis and Peritonsillar Abscess

• These are "classical" ENT diseases causing acute dysphagia and should be identified through direct visualization 5, 6
• Peritonsillar abscess presents with severe odynophagia, trismus, and deviation of the uvula 6

Retropharyngeal Abscess

• Causes referred otalgia and dysphagia, particularly in the context of recent upper respiratory infection 1
• Requires urgent imaging and surgical drainage 1

Trauma-Related Causes

Post-Intubation Injury

• Prolonged mechanical ventilation causes dysphagia in 70-80% of patients after weaning, predominantly due to critical illness polyneuropathy 1
• Associated with significantly longer artificial respiration, prolonged artificial nutrition, and increased mortality 1

Cervical Spine Trauma or Surgery

• Congenital or acquired cervical spine diseases, inflammatory or degenerative processes, and previous cervical spine surgery can cause acute dysphagia 5
• Consider with positive history of cervical spine intervention, chronic back pain, or trauma 5

Malignant Tumors

• Oropharyngeal and hypopharyngeal malignancies often present with dysphagia at advanced stages 6, 7
• Red flags: Progressive dysphagia (solids to liquids), weight loss, anemia, older patients with tobacco/ethanol use history, or younger patients with HPV infection 1, 2
• Complete inability to swallow saliva requires emergency endoscopy within 2-6 hours 2

Referred Otalgia Masquerading as ENT Dysphagia

While not primary ENT causes, these must be excluded:

• Temporomandibular joint syndrome: Pain radiating to periauricular area, temple, or neck; tenderness over TMJ with possible crepitus 1
• Dental pathologies: Caries, impacted molars causing referred pain and secondary dysphagia 1
• Carotidynia, styloid process elongation, glossopharyngeal neuralgia: Rare but important differential diagnoses 1

Diagnostic Approach for Acute ENT Dysphagia

Immediate Assessment

• History: Timing of onset (acute vs. progressive), witnessed foreign body ingestion, recent trauma or intubation, fever, ability to handle secretions 1, 2
• Physical examination: Fever, cervical subcutaneous emphysema, erythema/tenderness, stridor, drooling, wet voice 1, 2
• Indirect laryngoscopy: Mandatory to visualize epiglottis, pharynx, and larynx 3, 4

Imaging

• Plain radiographs (neck, chest, abdomen): Initial screening for radiopaque foreign bodies, but false-negative rate up to 47% for single view, 85% for food boluses and thin bones 1
• CT scan: Sensitivity 90-100% for fish bone impaction; essential when perforation suspected or plain films negative with high clinical suspicion 1
• Lateral soft-tissue neck X-ray: Useful for epiglottitis diagnosis showing swollen epiglottis 3

Endoscopy

• Timing: Emergency endoscopy within 2-6 hours for complete esophageal obstruction with inability to swallow saliva 2
• Indications: Suspected perforation, failed conservative management, or need for foreign body removal 1