Functional (e.g. ‘express’ swallowing, psychogenic)
Serious disorders not to be missed
AIDS (opportunistic oesophageal infection)
Stricture, usually benign peptic stricture
Drugs (e.g. phenothiazines)
Extrinsic lesions (e.g. lymph nodes, goitre)
Upper oesophageal web (e.g. Plummer–Vinson syndrome)
Upper oesophageal spasm (mimics angina)
aberrant right subclavian artery
cervical osteoarthritis (large osteophytes)
other neurological causes
other mechanical causes
Is the patient trying to tell me something?
Yes. Could be functional ?globus hystericus.
Analyse the nature of the symptom: difficulty in swallowing. Its origin is either oropharyngeal or oesophageal. A careful history includes a drug history and psychosocial factors.
Focus on the patient’s general features, mouth, oropharynx, larynx, neck (esp. lymphadenopathy and thyroid) and any abnormal neurological features especially cranial nerve function and muscle weakness disorders
The primary investigation in suspected pharyngeal dysphagia is a video barium swallow, while endoscopy is generally the first investigation in cases of suspected oesophageal dysphagia.
Dysphagia must not be confused with globus hystericus, which is the sensation of the ‘constant lump in the throat’ although there is no actual difficulty swallowing food.
Mechanical dysphagia represents cancer until proved otherwise.
Be careful of a change in symptoms in the presence of longstanding reflux (consider stricture or cancer).