Synopsis
Localise swallowing difficulty to oral, pharyngeal or oesophageal phases, protect the airway and nutrition, and choose speech-and-language or gastrointestinal investigations from the observed mechanism.
- Difficulty initiating a swallow, nasal regurgitation and immediate cough point toward oropharyngeal dysfunction.
- A sensation of food sticking after the swallow, especially behind the sternum, supports oesophageal dysphagia but perceived level is imprecise.
- Ask separately about solids, liquids, speed of progression, odynophagia, regurgitation, aspiration and weight loss.
Key red flags
Coughing, wet voice, oxygen change or recurrent chest infection around meals suggests aspiration, which may be silent in neurological disease.
Progressive oesophageal dysphagia, weight loss, iron-deficiency anaemia or persistent vomiting requires urgent assessment for malignancy.
Immediate cough, repeated swallows, wet voice and respiratory change after intake indicate impaired airway protection, but absence of cough cannot exclude silent aspiration.
Reasoning priorities
Form a hypothesis about phase, aspiration risk and safe immediate intake.
An SLT integrates alertness, cranial motor findings, secretion control, voice and observed bolus trials; bedside assessment can miss silent aspiration and may lead to instrumental testing.
Worked reasoning
After a new stroke, an adult coughs immediately with water, has a wet voice and repeatedly holds food in the right cheek.
- Recognise oral and pharyngeal dysfunction with immediate aspiration risk, pause oral intake, give mouth care and arrange urgent speech-and-language assessment while providing prescribed hydration and essential medicines by a safe alternative route.
- Bedside assessment remains uncertain, so FEES is performed: secretions pool in the hypopharynx and thin fluid enters below the vocal folds after the swallow without a protective cough; repeated trials of mildly thick fluid and purée show no airway entry.
- Implement the consistencies and positioning actually tested on FEES, with direct supervision, slow small boluses and a written mouth-care and escalation plan; continue supplementary hydration until the recorded oral-fluid target is met.
- Over five days the patient meets the fluid target without respiratory deterioration. Repeat FEES shows improved secretion control but persistent silent aspiration of thin fluid, so the tested plan is continued and a further SLT review date is recorded rather than advancing texture from symptoms alone.