Dysphagia is a nonspecific symptom that refers to difficulty in swallowing. When present, it should be considered a red flag feature for a potentially serious underlying condition and should be evaluated thoroughly. Oropharyngeal dysphagia refers to difficulty in initiating the swallowing process and is typically associated with coughing or choking. Esophageal dysphagia refers to the impaired passage of a food bolus from the esophagus to the stomach. Dysphagia predominantly with solid foods is usually caused by a mechanical obstruction (e.g., esophageal stricture, oropharyngeal abscess). Dysphagia with liquids and solid food typically indicates a neuromuscular disorder (e.g., esophageal motility disorders, neurodegenerative conditions). Acute dysphagia is commonly caused by food bolus impaction or stroke. Depending on the suspected etiology, the diagnostic workup can include an endoscopic evaluation of the nasopharynx and/or esophagus, a barium swallow, and high-resolution manometry. Neuroimaging and laboratory studies should also be considered as needed. Supportive therapy (e.g., swallowing rehabilitation, measures to minimize aspiration risk) is the mainstay of management, especially in patients with oropharyngeal dysphagia; etiology-specific management (e.g., esophageal dilation, antimicrobials for infectious esophagitis) may be feasible in some conditions. In elderly patients with dysphagia, goals of care should be discussed before considering interventional management.
Dysphagia: any difficulty swallowing, which can be divided into the following subtypes
- Oropharyngeal dysphagia: difficulty initiating the swallowing process
- Esophageal dysphagia: the impaired passage of solid food and liquid through the esophagus towards the stomach
- Motility-related dysphagia: dysphagia due to a neurological or muscular defect
- Structural dysphagia: dysphagia due to a mechanical or anatomical obstruction
- Aphagia: the inability to swallow
- Presbyphagia: the characteristic changes and mild decline in swallowing function seen in older adults; typically asymptomatic 
- Odynophagia: a painful sensation triggered by swallowing
The following table provides an overview of the etiologies of nonacute dysphagia.is a common cause of acute dysphagia but is often triggered by an underlying esophageal etiology.
|Overview of causes of dysphagia |
|Motility-related dysphagia||Structural dysphagia|
|Oropharyngeal dysphagia|| |
|Esophageal dysphagia|| |
Do not assume a diagnosis of presbyphagia in elderly patients with difficulty swallowing. Dysphagia is an alarm symptom and should be investigated thoroughly to determine its underlying etiology and start appropriate treatment.
A detailed clinical history and physical examination in patients with dysphagia can help categorize symptoms and select the best initial diagnostic test.
Clinical evaluation 
- Observe a swallow.
- Identify .
- Perform a complete physical examination, with particular importance to
- Identify the likely etiology based on history and examination.
- Select the appropriate initial diagnostic test based on the likely site and location of dysphagia.
Acute dysphagia can be caused by food impaction or a stroke and requires prompt evaluation.
Characterization of dysphagia
|Clinical characterization of dysphagia |
|Description of dysphagia||Possible associated findings and conditions|
|Esophageal dysphagia|| |
|Motility-related dysphagia|| |
|Structural dysphagia|| |
Dysphagia predominantly with solid food should raise suspicion for an underlying structural disorder, including malignancy. Dysphagia predominantly with liquids is suggestive of an esophageal motility disorder. 
Red flags for dysphagia 
- > 50 years of age at onset
- Clinically significant involuntary weight loss
- Symptom progression over a short period of time (e.g., < 4 months) 
- Evidence of GI bleeding
- Recurrent vomiting
- History of cancer
Elderly patients with recent pneumonia should be screened for dysphagia. 
Initial diagnostics 
See dedicated sections below for details.
- Oropharyngeal dysphagia: modified barium swallow
- Esophageal dysphagia
- Consider neuroimaging and supplementary laboratory studies as needed, guided by the pretest probability of the underlying etiology.
|Common etiologies of oropharyngeal dysphagia |
|Characteristic clinical features||Diagnostics|
|Neuromuscular disorders|| CNS disorders |
Obstructive and structural causes
Head and neck malignancies 
|Secondary to treatment, interventions, or injury || |
|Zenker diverticulum || |
Oropharyngeal dysphagia is commonly caused by neuromuscular and systemic conditions.
A multidisciplinary evaluation involving speech-language pathologists, neurologists, and otolaryngologists is recommended for a comprehensive evaluation.
Endoscopic evaluation of the nasopharynx
- Structural assessment: nasopharyngeal laryngoscopy
- Functional assessment: fiberoptic endoscopic evaluation of swallowing (FEES)
- Pharyngoesophageal high-resolution manometry : Can help identify patients who are likely to benefit from a myotomy 
Consider EGD to rule out an esophageal etiology for dysphagia in patients in whom an oropharyngeal etiology has been ruled out.. 
Management is primarily supportive and should be tailored to each patient, focus on symptom control, minimize aspiration risk, and ensure adequate nutrition. Goals of care should be discussed before considering interventional therapy (including enteral feeding) for dysphagia in elderly patients.
- Swallowing rehabilitation: compensatory strategies aimed to direct the bolus towards the esophagus and minimize aspiration risk 
- Optimization of nutrition
- Management of the underlying cause, e.g.:
- Aspiration prevention surgery 
Common etiologies of esophageal dysphagia 
|Characteristic clinical features||Diagnostics||Management|
| Esophagitis |
(most common cause of dysphagia) 
|Functional esophageal disorders (e.g., nonerosive reflux disease, reflux hypersensitivity) || |
Structural and obstructive disorders
||| || |
||| || |
|Esophageal webs or esophageal rings || |
||| || |
Extrinsic compression |
| || |
Motility-related disorders (uncommon) 
|Esophageal hypermotility disorders |
Consult a gastroenterologist early for a comprehensive evaluation. 
- Esophagogastroduodenoscopy (EGD): preferred initial test for most patients 
- Consider as an initial test in the following cases:
- Second-line test (adjunct) if initial EGD is normal 
- High-resolution esophageal manometry
- Thoracic imaging: if extrinsic esophageal compression is suspected (e.g., due to goiter, thoracic aortic aneurysm, mediastinal mass)
In patients < 50 years of age with characteristic features of GERD and no alarm features for malignancy, a trial of empiric treatment with PPIs for 4 weeks may be considered. Persistent dysphagia despite empiric treatment necessitates evaluation by EGD. In all patients with unexplained solid food dysphagia, biopsies should be obtained from normal-appearing mucosa of the mid-third and distal esophagus to evaluate for eosinophilic esophagitis. 
Depends on the underlying cause. See “Overview of esophageal dysphagia” and dedicated articles for details; examples include:
- Pharmacotherapy: e.g.,
- Endoscopic intervention
- Supportive therapy: Optimize nutrition of patients with dysphagia refractory to therapy.
In older patients, discuss goals of care before considering interventional therapy. 
Clinical features 
- Acute dysphagia, often after eating meat
- Aphagia and drooling indicates complete esophageal obstruction.
Management: prompt endoscopic removal of the bolus 
- IV glucagon for esophageal relaxation may be trialed but should not delay endoscopic intervention.
- Complete obstruction: emergency endoscopy
- Incomplete obstruction: urgent endoscopy, ideally within 24 hours
- The impacted bolus may either be extracted perorally or broken into smaller pieces and gently pushed into the stomach.
- The esophageal mucosa should be evaluated to determine if an underlying structural pathology triggered the impaction.
- If no structural pathology is identified, multilevel biopsies should be obtained to assess for eosinophilic esophagitis.
Esophageal food bolus impaction partially or completely obstructs the esophagus and should be treated promptly to avoid complications, such as a perforation, esophagitis, or fistula formation. 
- Esophageal bolus impaction: usually manifests as acute dysphagia
- oropharyngeal dysphagia: common complication of 
- (see “ ” for management)
We list the most important complications. The selection is not exhaustive.