Rationale

Dysphagia, defined as difficulty swallowing, should be regarded as a clear signal of potentially serious organic pathology, which therefore warrants careful and complete evaluation.

Causal Conditions

(list not exhaustive)

1. Oropharyngeal dysphagia

   1. Structural

      • Peritonsillar abscess

      • Pharyngitis

      • Tumour

      • Zenker diverticulum

   2. Neuromuscular

      • Central (e.g., cerebrovascular accident)

      • Cranial nerves (e.g., amyotrophic lateral sclerosis)

      • Systemic myopathies (e.g., dermatomyositis)

   3. Xerostomia

2. Esophageal dysphagia

   1. Mechanical obstruction

      • Intrinsic

      • Extrinsic (e.g., mediastinal mass)

   2. Neuromuscular disorder

      • Intermittent (e.g., diffuse esophageal spasm)

      • Progressive (e.g., scleroderma, achalasia)

Key Objectives

Given a patient with dysphagia, the candidate will differentiate oropharyngeal from esophageal causes and initiate a management plan based on the underlying cause and severity.

Enabling Objectives

Given a patient with dysphagia, the candidate will

1. list and interpret critical clinical findings, including

   1. determining from the history whether the problem is most likely oropharyngeal or upper or lower esophageal;

   2. identifying the characteristics of the esophageal dysphagia that suggest specific underlying disorders; and

   3. determining complication risk;

2. list and interpret critical investigations, including determining whether specific investigations are required (e.g., barium swallow, endoscopy); and

3. construct an effective initial management plan, including

   1. determining whether the patient needs specialized care and

   2. anticipating short-, medium-, and long-term complications (e.g., aspiration).