Synopsis
Localise swallowing difficulty to oropharyngeal or oesophageal phases, recognise aspiration, food-bolus obstruction and cancer risk, and sequence endoscopy, swallow imaging and manometry safely.
- Ask where initiation fails rather than where food feels stuck: coughing, nasal regurgitation, wet voice and repeated swallows suggest oropharyngeal dysfunction even when the patient points to the neck.
- Oesophageal dysphagia to solids first suggests mechanical narrowing, while difficulty with both solids and liquids from onset supports motility disease; neither rule is absolute.
- Progressive dysphagia, weight loss, iron-deficiency anaemia or older-age new onset needs the current urgent oesophageal cancer pathway and prompt endoscopy.
Key red flags
Delayed initiation, coughing during swallowing, nasal regurgitation, wet voice, repeated swallows, drooling or neurological signs localise towards oral or pharyngeal dysfunction and carry immediate aspiration and nutrition risk.
Investigation priorities
Determine whether oral intake and medicines are safe immediately after acute stroke or neurological deterioration.
Management branches
The patient cannot swallow saliva or has respiratory compromise after eating.
- Assess airway, breathing and haemodynamics, keep the patient nil by mouth, remove loose oral material only when safely visible and call senior endoscopy and anaesthetic support.
- Establish time and food or foreign-body type, anticoagulants, prior impactions and perforation features; avoid forceful oral intake or blind instrumentation.
Key medicines
Proton-pump inhibitor for reflux-related injuryUse the current full-dose BNF regimen for documented reflux oesophagitis or peptic stricture, then review healing, symptoms and the long-term maintenance indication.