How can I differentiate between oropharyngeal and esophageal dysphagia during a clinical assessment?

To differentiate between oropharyngeal and esophageal dysphagia during clinical assessment, focus on the timing, symptoms, and associated signs reported by the patient and observed by the clinician.

Oropharyngeal dysphagia typically presents with difficulty initiating a swallow, coughing, choking, nasal regurgitation, or a sensation of food sticking in the throat immediately upon swallowing. Patients often describe problems with the transfer of food from the mouth to the throat, and may have associated neurological symptoms such as hoarseness or drooling. Clinical examination may reveal signs of neuromuscular dysfunction affecting the oropharynx, such as weak gag reflex or impaired laryngeal elevation (Rommel and Hamdy, 2016; ¹).

In contrast, esophageal dysphagia usually manifests as a sensation of food sticking or obstruction occurring after the swallow, often described as a delay or blockage in the lower throat or chest. Patients may report that solids are more problematic than liquids and may have associated symptoms such as heartburn or regurgitation. There is typically no coughing or choking during swallowing, and the problem is related to the passage of the bolus through the esophagus rather than the initiation of swallowing (Kruger, 2014; Expert Panel on Gastrointestinal Imaging, 2019; ¹).

Key clinical distinctions include:

• Onset of symptoms: Oropharyngeal dysphagia causes immediate swallowing difficulty; esophageal dysphagia causes delayed sensation of obstruction.
• Associated symptoms: Oropharyngeal dysphagia often involves coughing, choking, nasal regurgitation; esophageal dysphagia may involve heartburn or regurgitation without airway symptoms.
• Swallowing phases affected: Oropharyngeal dysphagia affects the oral and pharyngeal phases; esophageal dysphagia affects the esophageal phase.

Thus, a detailed history focusing on the timing of symptoms relative to swallowing, associated airway symptoms, and the nature of the bolus difficulty is essential. Clinical examination should assess for neuromuscular deficits in the oropharynx. This integrated approach aligns with UK clinical guidelines and is supported by recent literature emphasizing the importance of symptom timing and associated features in differentiating these two types of dysphagia (Rommel and Hamdy, 2016; Kruger, 2014; Expert Panel on Gastrointestinal Imaging, 2019; ¹).