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18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase
Table 18.17 A differential diagnosis of complete airway obstruction
Symptoms or history/complete airway obstruction D/D
H/O FB aspiration present, choking, gasping, agitation,
cyanosis, sudden onset
Progressive dyspnoea, change of voice, dysphagia Tumours of larynx
Table 18.18 Differential diagnosis of partial airway obstruction
Symptoms/chief complaints/presentation of partial airway
obstruction Differential diagnosis
H/O FB aspiration Foreign body in bronchus, trachea
Hoarseness of voice, dysphagia, H/O smoking or alcohol intake Tumours of larynx, laryngopharynx
Progressive dyspnoea, +/− H/O haemoptysis, cough
H/O dyspnoea +/− hoarseness of voice
Foreign body in trachea, subglottis, glottis and
supraglottis
Endotracheal tumour
Mediastinal mass/tumour/nodes
483
Congenital Acquired
Retrognathia—Pierre robin
syndrome, Treacher Collin
syndrome, Goldenhar’s
syndrome
Choanal atresia Infection—Croups,
Macroglossia—Down’s
syndrome, BeckwithWiedemann,
mucopolysaccharidoses
Larynx—Laryngomalacia,
laryngeal web, laryngeal
cleft, vocal cord palsy,
subglottic stenosis,
haemangioma
Tracheal—Tracheomalacia,
tracheal stenosis
Vascular ring
Physical obstruction—
FB, trauma,
angioedema, thermal
injury
quinsy, tracheitis,
retropharyngeal abscess
Tumour—Carcinoma
larynx, tracheal tumour,
bronchogenic
carcinoma, mediastinal
tumours
Post intubation—
Subglottic stenosis, cyst
• Associated symptoms/history of a
patient with dyspnoea/respiratory
obstruction
– Choking—Gagging following the
initial inhalation of the object,
coughing, wheezing, a panicking
look, lips turning blue, lack of
breathing, inability to speak
– Anaphylaxis—Hives, tightness in
the throat, trouble breathing, a
hoarse voice, vomiting, abdominal
pain, dizziness, rapid heartbeat, low
blood pressure
– Heart attack—Chest discomfort,
trouble breathing, lightheadedness,
cold sweat
– Laryngeal symptoms—Hoarseness
of voice, throat pain, neck swelling
– Neck symptoms—Neck swelling,
dysphagia
– H/O nervousness, anxiety, wheez-
ing, chronic cough, tightness of
chest, difculty in sleeping due to
coughing, inhaling or swallowing a
foreign object, drug intake, food
intake, inhalational injury, neck
injury, maxillofacial injury
– Past H/O—Hoarseness of voice,
dysphagia, odynophagia, cough,
haemoptysis, throat pain, chest
pain, burning sensation in the
throat, neck swelling
– Medication history—Beta-blockers
(exacerbate the bronchospasm)
– H/O smoking—Chronic bronchitis
(COPD), allergy (asthma), anxiety
– H/O, hypertension, lightheaded-
ness, tightening in ngers and peri
oral area
484
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
– Family history of asthma, allergy,
chronic bronchitis, hay fever
– H/O occupational exposure like
dust, asbestos or volatile chemicals
(interstitial lung ds)
18.1.3 Stridor
It is a harsh, high-pitched, vibrating sound that is
heard in respiratory tract obstruction. The Stridor in
inspiratory phase of respiration is known as inspiratory stridor and it is caused by upper respiratory
tract obstruction i.e. FB in bronchus, carcinoma
larynx, bilateral vcal cord paralysis. Stridor in the
inspiratory phase is usually heard with obstruction
in the upper airways, such as the trachea, epiglottis
or larynx; because a block here means that no air
may reach either lung, this condition is a medical
emergency. Biphasic stridor (occurring during both
the inspiratory and expiratory phases) indicates
narrowing at the level of the glottis or subglottis,
the point between the upper and lower airways.
Stridor may also be called musical breathing or
extra-thoracic airway obstruction. Airow is usually disrupted by a blockage in the larynx (voice
box) or trachea (windpipe). A thorough history
may provide helpful clues to the underlying aetiology of stridor. Particular emphasis should be placed
on the following:
• History/chief complaints of a patient with
stridor
– Presentation of stridor—It is presented as
an abnormal, high-pitched sound. Its
tonal characteristics are extremely variable
like harsh, musical or breathy. However,
when combined with the phase, volume,
duration, rate of onset and associated
symptoms, the tonal characteristics of the
sound may provide additional diagnostic
clues.
– Types of stridor—There are three types of
stridor
Inspiratory stridor—When the abnormal sound is heard during inspiration.
This indicates upper airway
obstruction.
Biphasic stridor—When the abnormal
sound is heard during both phases of
respiration. This indicates the middle
airway obstruction.
Expiratory stridor—When the abnormal
sound is heard during expiration. This
indicates the lower airway obstruction.
– Duration of stridor—It can be of short
duration or long duration
Acute stridor—Acute epiglottitis,
angioedema, poisoning, trauma, FB
inhalation.
Chronic stridor—Laryngeal papillomatosis, laryngeal amyloidosis, carcinoma
larynx, benign tumours of larynx.
– Age of onset
Adult onset—Carcinoma larynx, trans
glottic carcinoma, subglottic carcinoma,
B/L abductor palsy.
Juvenile onset—Laryngeal papillomatosis, laryngomalacia, subglottic stenosis, subglottic haemangioma.
– Severity
Mild—Rinke’s oedema.
Moderate—FB in larynx, benign tumour
of larynx, subglottic stenosis.
Severe—Carcinoma larynx, B/L abductor palsy.
– Progression of the stridor
Progressive—Carcinoma larynx, laryngeal papillomatosis, amyloidosis, angioedema, trauma.
Non-progressive—FB in the larynx or
trachea, benign tumour of the larynx.
– Precipitating events (e.g. crying or
feeding)
– Positioning (e.g. prone, supine or sitting)
– Quality and nature of crying
– Presence of aphonia
– Other associated symptoms (e.g. parox-
ysms of cough, aspiration, difculty in
feeding, drooling or sleep-disordered
breathing)
– Perinatal history—Regarding maternal
condylomata, type of delivery (including
shoulder dystocia), endotracheal intubation
uses and duration, and presence of congen-
ital anomalies.
18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase
– H/O surgical history of thyroid surgery,
cardiothoracic procedure, cyanotic spell.
– H/O regurgitation and spitting up could be
a sign of gastroesophageal reux (GER),
which can cause laryngeal and tracheal
mucosal irritation that could lead to oedema
and stridor.
• Causes of stridor
– Causes of stridor in adults (Table 18.19)
– Causes of stridor in children (Table
18.20)
– Causes of acute and chronic stridor
(Table 18.21)
Table 18.19 Causes of stridor in adults
Inspiratory Biphasic Expiratory
Vocal cord paralysis
Epiglottitis
Carcinoma larynx
Laryngopharynx
Carcinoma of the thyroid involving
the larynx or vocal cords
Retropharyngeal abscess
Anaphylaxis
Subglottic carcinoma
Subglottic mass
Tracheal tumours
Subglottic stenosis
Mediastinal mass/node
Clinical Grades of Stridor
Grade 1—(Stridor on exercise)—Stridor
appears during exercise or crying.
Grade 2—(Stridor on rest)—Stridor
present at rest and increased on exercise.
Grade 3—(Stridor with retraction)—
Stridor is continuous and accompanied by
suprasternal and/or supraclavicular retraction. The patient is anxious, irritable and
struggling for breathing.
Grade 4—(Stridor with cyanosis)—Grade
3 plus cyanosis and altered consciousness.
COPD
Bronchial Asthma
Pulmonary TB
Lung brosis
Atelectasis
485
Table 18.20 Causes of stridor in children
Inspiratory Biphasic Inspiratory
Laryngomalacia
Respiratory papillomatosis
Table 18.21 Causes of acute and chronic stridor
Acute stridor Chronic stridor
Children Adult Children Adult
Cruop
Pseudo-croup
Aspiration of FB
Bacterial tracheitis
Retropharyngeal
abscess
Peritonsillar abscess
Spasmodic croup
Anaphylaxis
Epiglottitis
Anaphylaxis
Acute Epiglottitis
Supraglottic laryngitis
B/L vocal cord
paralysis
Croup
Subglottic stenosis
Subglottic haemangioma
Vascular ring
Laryngomalacia
Subglottic stenosis
Vocal cords dysfunction
Subglottic haemangioma
Congenital laryngeal cyst
Laryngeal papillomatosis
Tracheomalacia
Tracheal stenosis
Laryngeal dyskinesia
Exercise induced
laryngomalacia
Paradoxical vocal cords motion
Tracheomalacia
Stenosis of proximal trachea
Vascular ring
Double aortic arch
Asthma
Carcinoma larynx
Ca hypopharynx
Ca oesophagus
Ca subglottis
Subglottic stenosis
Transtracheal mass/
granulation
Benign tumours of the larynx
486
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
18.1.4 Wheeze
Wheezing is the shrill whistle or coarse rattle
sound. It is heard when the airway is partially
blocked because of an allergic reaction, a cold,
bronchitis or allergies. Wheezing is also a symptom of asthma, pneumonia, heart failure, etc.
Wheezes occupy different portions of the respiratory cycle depending on the site of airway obstruction and its nature. The fraction of the respiratory
cycle during which a wheeze is produced roughly
corresponds to the degree of airway obstruction.
As a rule, extra-thoracic airway obstruction produces inspiratory sounds. Intrathoracic major airway obstruction produces inspiratory as well as
expiratory sounds. Distal airway obstruction predominantly produces expiratory sounds, for
example, bronchoalveolar disease.
• Presentation/history of wheeze—Wheeze
presents as a musical, high-pitched, whistling
sound
• Severity of wheeze
– Mild—If wheeze is present in an end-
expiratory phase of respiration.
– Moderate—If wheeze is present through-
out expiation.
– Severe—If wheeze is present in both the
expiratory and inspiratory phases of
respiration.
• Pattern of wheeze
– Episodic wheeze—It is dened as wheez-
ing during a discreet time period with
absence in between episodes.
– Multiple triggered wheeze—Wheeze with
discrete exacerbations but also present in
between episodes.
• Onset of wheeze
– Transient—The symptoms that com-
menced before the age of 3 and disappeared
by the age of 6 can be episodic or multiple
triggered.
– Persistent—The symptoms that persist
more than 6 years of age. It can be episodic
or multiple triggered.
– Late-onset wheeze—The symptoms start
after the age of 3.
• Duration of wheeze
– Acute—RTI, acute epiglottitis, FB
aspiration
– Chronic—Asthma, COPD, lung cancer,
cystic brosis
• Type of wheeze
– Inspiratory—It is also known as stridor,
RTI, acute epiglottitis
– Expiratory—Asthma, COPD, lung can-
cer, bronchitis, FB aspiration, cystic
brosis
• Associated symptoms—Dyspnoea, hoarse-
ness of voice, fever
• Causes of wheeze (Table 18.22)
18.1.5 Stertor
snoring or noisy breathing, which occurs above
the larynx. It is caused by partial obstruction of
the upper airways, at the level of the nose, nasopharynx and pharynx. Stertor is the noise that
results from the vibration of the pharyngeal tissues (nasopharynx, oropharynx, soft palate) due
to signicant upper respiratory obstruction and
subsequent turbulent airow downstream in the
upper airway. This term implies a noise created in
the nose or the back of the throat. It can be distinguished from stridor by its pitch and affects children more often than adults. Stertor is a
low-pitched noise, while stridor is a high-pitched
noise.
Table 18.22 Causes of wheeze
Infection Allergic reaction Obstructive lesion
Pneumonia, RTI, acute epiglottitis Asthma, anaphylaxis, COPD, lung cancer, bronchitis
FB aspiration, cystic brosis
18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase
• Lower extremities—Oedema, signs of
deep vein thrombosis
• Upper extremities—Clubbing
causing hypotonia.
tic hygroma, cause extrinsic compression
Causes of Stertor
of the upper airway.
Nose
487
Congenital neurological conditions
Congenital neck masses, such as a cys-
Congenital—Choanal atresia, craniofacial
anomaly, nasal trauma, dermoid, meningoencephalocele, meningocele, glioma,
etc.
Acquired—Nasal trauma, olfactory neuro-
blastoma, Wegener’s granulomatosis,
nasal polyp, rhinosinusitis, DNS with
HIT, B/L HIT.
Nasopharynx
Congenital—Dermoid, Crouzon’s syn-
drome, Apert’s syndrome.
Acquired—Adenoid hyperplasia, JNA,
NPC, parapharyngeal abscess, retropharyngeal abscess.
Oral cavity and oropharynx
Micrognathia, craniofacial abnormality
(Treacher Collins and Pierre Robin
syndromes).
(In these, a small mandible and hypotonia
allow the normal-sized tongue to ll the
mouth and, by falling backwards (glossoptosis), obstruct the oropharynx.)
Macroglossia—True macroglossia, mac-
roglossia due to congenital masses such
as a haemangioma or lymphangioma or
as part of a syndrome such as BeckwithWiedemann syndrome. Such lesions
obstruct both the oral cavity and the oropharynx. Relative macroglossia due to a
small mouth without micrognathia, but
normal tongue, most frequently in children with Down’s syndrome, Lingual
thyroid and thyroglossal cyst.
Presentation of stertor—Stertor presents as
low-pitch sound during breathing while sleeping
or awake.
Differences among stridor, stertor, wheeze,
crepitus and rhonchi: diagnostic clues to differentiate (Tables 18.23 and 18.24).
Examination of a patient with airway nontraumatic emergency, e.g. Obstruction/
Respiratory difculty/Dyspnoea/Stridor/
Stertor/Wheeze
(a) General examination—Dyspnoeic patients
frequently breathe rapidly and shallowly. The
accessory muscles of respiration may be used,
and supraclavicular and intercostal retractions
may be seen. Cardiac, pulmonary and neuromuscular examinations should receive particular attention in patients with dyspnoea. To
determine the severity of dyspnoea, one should
carefully observe respiratory effort, use of
accessory muscles, mental status and ability to
speak. Pulsus paradoxus may exist in COPD,
asthma, cardiac tamponade or pericardial constriction. Stridor indicates upper airway
obstruction. It may be necessary to obtain a
rectal temperature to detect fever, as oral airow may decrease the oral temperature.
• Physical appearance—Including signs of
any bluish tinge to the skin (cyanosis),
pallor
• Tachypnoea or apnoea
• Clammy skin—The head may be sweaty
while the skin feels cool or clammy
• Mood change—Sleepier, difcult to
wake, fussier than usual
• Degree of respiratory distress (mild, moderate or severe)
488
Table 18.23 Differences between stridor and stertor
Stridor Stertor
This is a high-pitched sound, which usually occurs
during inspiration, and is heard loudest in the neck
It can be inspiratory, expiratory or biphasic It can be inspiratory or biphasic
Neck position-neck exion may change the intensity of
the stridor, suggesting a thoracic outlet obstruction
Added features—The character of a patient’s voice may
be a clue to an upper airway obstruction. Hoarseness
may be a sign of a laryngeal abnormality, and mufing
of the voice without hoarseness may indicate supraglottic lesions
Causes—Carcinoma larynx, B/L abductor palsy, tumour
of larynx, angioneurotic oedema, FB in glottis or
trachea, subglottic stenosis, laryngomalacia,
tracheomalacia, croup
Presentation—Difculty in breathing, noisy breathing,
hoarseness of voice, dysphagia, odynophagia
Table 18.24 The difference between wheezing, rhonchi and crepitus
Wheezing Rhonchi Crepitus
Wheezing is a high-pitched noise
characteristic of diffuse lower
airway narrowing, occurs
predominantly during expiration and
gets louder at end-expiration
Causes are asthma, bronchitis,
COPD, bronchiolitis, cystic brosis,
pneumonia, respiratory syncytial
virus, aspiration, vocal cord
dysfunction, allergy, anaphylaxis
Smoking
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
This is a low-pitched sound produced at the level of the
nose, nasopharynx and oropharynx
It increases in the supine position
Not associated with specic neck position
No change of voice; patient may have associated nasal
symptoms
Causes—Nasal polyp, URI, choanal atresia, dermoid,
meningocele, glioma, adenoid, JNA, Cyst, NPC,
micrognathia, macroglossia, choanal atresia, DNS
The patient presents with a gurgling type of sound, with
nasal problems: nasal mass and nasal obstruction
These are continuous gurgling
sounds typically heard on
auscultation of the chest during
expiration
Asthma, COPD, bronchitis
Aspiration
Anaphylaxis
Vocal cord dysfunction
It is dened as a crackling sound
heard on auscultation of the chest
during inspiration or expiration
Pneumonia
Pulmonary oedema
Interstitial lung diseases
Tuberculosis
Heart failure
• Neck—Distension of neck vein—Cor
pulmonale
• Thyroid swelling
• Change in body position
• Ability to feed
• Breathing function—No breathing, alterations in normal breathing pattern—rapid
or shallow breathing
• Tachycardia
• Vital signs tests, such as pulse, blood
pressure and temperature readings
• Flaring of the nostril (use accessory
muscles)
• Trismus—Grade of trismus
• Bluish skin colour (cyanosis)—Chronic
severe hypoxia
• Unconsciousness/responsiveness
• Paradoxical ‘see-saw’ movement of the
abdomen and chest will occur due to
inspiratory effort against a closed
airway
• Patient with a partial airway obstruction
may be panicked and agitated
• If distress is moderate to severe, further
physical examination should be deferred
until the patient reaches a facility equipped
for emergency management of the paediatric airway. Physical examination of a
patient with suspected acute epiglottitis is
contraindicated
• Infection of the oral cavity
• Deviation of trachea
18.1 Trauma andEmergencies inENT, Head, Neck andSkullBase
489
(b) Local examination—Airway examination
• Upper airway examination
– Examination of nose and
nasopharynx
Examination of the nose for DNS,
nasal polyp and other nasal mass
Nasal aring
– Examination of oropharynx and
larynx
Inspiratory stridor—Its severity
may be from mild to severe depending on the severity of the
obstruction
Stertor—It is dened as low-pitchnoisy breathing resulting from the
narrowing of the pharyngeal
airway
Speech and voice function
Examination of throat for postnasal drip—Allergy, asthma
Indirect laryngoscopy—Status of
vocal cords, epiglottis, mass lesion
involving the base of tongue, supraglottis, glottis, subglottis, movement of vocal cords, oedema
Epiglottis—Omega shape (laryngomalacia) and swollen (epiglottitis)
• Lower airway (respiratory system/
chest) examination
Examination of the lower airway of
children
– Inspection
Intercostal and subcostal retraction—Mild, moderate or severe
– Palpation
Palpatory thud—A FB in the trachea may move up and down the
trachea between the carina and the
undersurface of vocal cords causing
‘audible slap’ and ‘palpatory thud’
Audible slap the ‘audible slap’
produced from FB contact with the
trachea
– Auscultation
No breathing
Bilateral air entry
Crepitation or Rhonchi
Asthmatic wheeze
Examination of the lower airway of
an adult
– Inspection
Alterations in normal breathing pattern—Rapid or shallow breathing
No breathing
Stridor
Restlessness/agitation
Suprasternal retraction
Flaring of nostril
Intercostal recession
Increase AP diameter of the
chest—Emphysema
Wheezing—Asthma, pulmonary
oedema
– Palpation
Tachypnoea
Tachycardia
Lymphadenopathy
– Auscultation
B/L air entry
Decreased breath sounds in lungs
High-pitched breath sounds in the
upper airway or mouth
Rales/crepitation—Alveolar uid
(oedema)
Asthmatic wheeze
(c) Systemic examination
• Pulmonary/respiratory system examination
– Palpation
Subcutaneous emphysema, crepitus
– Percussion
Dullness—Consolidation, effusion
Hyperresonance—Pneumothorax,
bullous emphysema
• Cardiovascular examination
– Inspection
Jugular vein distension—
Congestive heart failure
– Palpation
Tachycardia—Anaemia, heart failure, hypothyroidism
Bradycardia—Peripheral vascular
disease
– Auscultation
Rales/crepitation—Alveolar uid
(oedema)
490
Table 18.25 Early and late signs of acute airway obstruction
Sign Early Late
Talking Able to talk in full sentence Unable to talk in full sentence
Stridor Soft Harsh/loud, quietening as the patient
Intercostal/subcostal recession Not present Present
Colour of skin and mucous
membrane
Respiratory rate 14–30 >30 or <14
Oxygen saturation 94% and above <94%
Heart rate 110–120 >120 or <60
Blood pressure Normal or high Decrease
Level of consciousness Obtundation due to hypercarbia Agitation due to hypoxia
Capillary rell time <2 s >2 s
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
tiring
Pink, well perfused Pale, blue
S3 sound—Congestive heart failure
Signs for severity of airway—Early and
late signs of acute airway obstruction
(Table 18.25)
• Medical advice is needed if an individual experiences:
– A change in their ability to breathe
– Increasing limits on their activities
due to breathing problems
When to seek medical evaluation or go to
the emergency room immediately if a
child or adult has noisy breathing with
any of the following symptoms:
– Difculty breathing when lying down
– Swelling in feet and ankles
– Fever, chills and a cough
– Wheezing
Pauses in breathing
Inability to talk
A colour change of the skin (particularly if
18.2 Acute Emergency ofSystem
the lips, face or hands are turning blue)
Drooling child
18.2.1 Acute Dysphagia
Suprasternal, subcostal and intercostal
retraction
Appearing lethargic or tired
Fever
Cough and sputum (thick or green
coloured)
Deglutition—Deglutition is the act of swallowing in which a food or liquid bolus is
transported from the mouth through the
pharynx and oesophagus into the stomach.
Normal deglutition involves a complex series
of voluntary and involuntary neuromuscular
contractions proceeding from the mouth to
• Emergency medical treatment is needed
if an individual has any of these
the stomach and is commonly divided into
oral, pharyngeal and oesophageal stages.
symptoms:
– Sudden onset of severe dyspnoea
– Loss of ability to function due to
shortness of breath
– Chest pain
– Nausea
Globus—Globus is the constant sensation of a
lump in the throat, although no organic defect
or true difculty in swallowing is apparent.
18.2 Acute Emergency ofSystem
491
Oesophageal
dysphagia
symptoms with solid food only
structural
Progressive
Slow
progressive
Oesophagis
Stricture
Fig. 18.1 Flowchart of approach to patient of dysphagia
Rapid
progressive
Carcinoma
Intermient
1- oesophageal
ring
2- Oesophageal
web
3- eosinophilic
oesophagis
Dysphagia—Difculty in swallowing (dysphagia) means it takes more time and effort to
move food or liquid from your mouth to your
stomach. Complaints of dysphagia (difcult
swallowing) are common, especially in ageing
persons. Approximately 7–10% of adults older
than 50 years have dysphagia. In addition, care
should also be taken not to confuse globus with
dysphagia. It can be acute or chronic depending
on duration and it can be oral, pharyngeal and
oesophageal dysphagia depending on phase of
swallowing involved (Fig.18.1).
Oral dysphagia—This is due to lesions in the
oral cavity like disorders of the tongue,
difculty in chewing, xerostomia, swelling, ulcer, cleft palate and palatal palsy.
Oropharyngeal dysphagia—The symptoms
arise from the dysfunctional transfer of
symptoms with both liquid and
progressive
H/O
chronic
heart
burn
Scleroder
ma
solid
molity
disorders
H/O
regurgita
on
Achalasia
cardia
intermient
H/O
chest
pain
Distal
esophage
al spasm
a food bolus in the pharynx past the
upper oesophagal sphincter into the
oesophagus. Oropharyngeal dysphagia
is most common in elderly patients and
frequently presents as part of a broader
complex of signs and symptoms that
lead the physician to a correct primary
diagnosis. Stroke is the leading cause of
oropharyngeal dysphagia.
Oesophageal dysphagia—Oesophageal
dysphagia is caused by disordered peristaltic motility or conditions that
obstruct the ow of a food bolus
through the oesophagus into the stomach. Achalasia and scleroderma are the
leading motility disorders, while carcinomas, strictures and Schatzki’s rings
are the most common obstructive
lesions.
492
18 History andExamination ofNon-traumatic Emergency ofENT, Head, Neck andSkull Base
(a) Presentation/chief complaints/history—A
carefully conducted patient history will
enable the physician to identify 80–85% of
the causes of dysphagia.
• What are the presenting complaints of
dysphagia—Patients who have dysphagia
may present with a wide variety of
complaints.
– Coughing or choking while
swallowing
– Abnormal sensation of food sticking in
the back of the throat or upper chest
when they are trying to swallow
– Aspiration while swallowing
– Cough while swallowing
– Not able to swallow food
– Drooling
– Regurgitation (food coming up in the
throat)
• Types of food
– Dysphagia to solid food—This is a
common complaint in obstructive
lesions of the pharynx and
oesophagus.
– Dysphagia to liquid—This is a com-
mon symptom in neurological lesions
like achalasia cardia.
– Dysphagia to both—This is a common
complaint of complete obstruction of
oesophagus.
• Mode of onset
– Sudden—FB ingestion, corrosive burn,
poisoning, stroke.
– Gradual—Stricture, carcinoma (lar-
ynx, hypopharynx, oesophagus), thyroid swelling.
• Severity of dysphagia—The severity
depends on the severity of the disease. It
can be mild, moderate or severe.
• Duration of dysphagia
– Acute dysphagia—FB ingestion, cor-
rosive burn, poisoning, stroke, retropharyngeal abscess.
– Chronic dysphagia—Stricture,
oesophageal web.
• Past history of long-term illness, alcohol
and tobacco use, drugs (NSAIDS, chemo-
therapeutic agent, antibiotic, KCl tablet,
anticholinergic, ACE inhibitors).
• Associated symptoms or history—
Trauma, fever, respiratory distress, odynophagia, neck swelling, psychiatric
illness, pain, hoarseness of voice, frequent
heartburn, malnutrition, weight loss, aspiration pneumonia.
• Differential diagnosis of dysphagia
based on history (Table 18.26)
History Suggestive of Aetiology of
Dysphagia
Sudden onset: FB or impaction of food on
a pre-existing stricture or malignancy, neurological disorders.
Progressive: Malignancy.
Intermittent: Spasms or spasmodic
episodes over an organic lesion.
Dysphagia more to liquids is seen in
paralytic lesions.
Dysphagia is more solids and progresses
even to liquids seen in malignancy or
strictures.
Ulcerative lesions cause intolerance to
acid food or fruit juices.
Regurgitation and heartburn (hiatus
hernia).
Regurgitation of undigested food while
lying down, with a cough at night (pharyngeal pouch).
Aspiration into the lungs (laryngeal
paralysis).
Aspiration into the nose (palatal
paralysis).
(b) Examination of patient with dysphagia
• General examination—A general physical examination and organ- or symptomsspecic examination based on history
often identify the aetiology of dysphagia.
– The presence of occult blood in the
stool may be a sign of neoplasms or
esophagitis.