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By Steph Le

Hey CPSolvers! Welcome to the first of the “How do I…” series on the CPSolvers blog!

This series is meant to reinforce simple “tools” that internists use to solve clinical problems.

As simple as some of these “how to’s” may be, they are often picked up along the way from repetition and re-exposure.

However simple, they can be pivotal in moving the diagnostic process forward. One of the best lessons I learned from a master clinician regarding how he came to seemingly master all things complicated, “Master the simple things, first.”

We hope you enjoy!


You’re a busy intern who has just admitted a patient for recurrent pneumonia.

She reveals to you that she’s had 30lb of weight loss over the preceding 6 months because she has been having trouble swallowing.

You want to determine whether her dysphagia is oropharyngeal or esophageal in order to decide further diagnostic and therapeutic work up (SLP for help or GI?), while also choosing the safest diet in your admission order.

How do I… differentiate between OROPHARYNGEAL and ESOPHAGEAL dysphagia?

    1. Make sure there is NO PAIN with swallowing → odynophagia, which triggers a workup for esophagitis!
    2. Start with OPEN ENDED questions
      • Have you had any issues with eating or drinking?
      • Have you had any issues with your voice/hoarseness?
    3. Ask the patient to POINT ANATOMICALLY TO THE AREA they have trouble with
      • Level of the throat → oropharyngeal
      • Suprasternal notch → oropharyngeal or esophageal
      • Chest/sternum → esophageal
    4. CAREFULLY OBSERVE the patient with a small amount of food/sip of liquid
      • Drooling/slippage of food outside of mouth → oral
      • Extended chewing and not able to initiate a swallow → oral
        • If this improves w/ taking a drink → possible component of inadequate saliva/sicca syndrome
      • Nasal regurgitation of food, followed by coughing/aspiration → oropharyngeal
      • Wet voice or cough after swallowing liquids → oropharyngeal
      • Frequent coughing shortly after initiation of swallow → oropharyngeal
      • CN IX-XII abnormalities → oropharyngeal
      • Nodding or sideways head movements to assist in the swallow → oropharyngeal
      • Feeling food gets “stuck” after several seconds after the swallow, in the chest → esophageal
        • If this improves w/ taking a drink → possibly a structural esophageal issue

To review the various causes of dysphagia, check out this schema!