Coughing while eating, a sensation of something getting stuck in the throat, or difficulty swallowing tablets may often be interpreted simply as “throat sensitivity.” However, swallowing is a complex function that extends from the mouth to the esophagus and requires the coordinated activity of numerous muscles and nerves. For this reason, current methods in dysphagia diagnosis aim to identify where and at which stage the problem occurs. Accurate evaluation is crucial both for planning safe nutrition and for treating the underlying cause.
Dysphagia means difficulty swallowing solid foods, liquids, or both. Not every swallowing difficulty develops for the same reason. In some patients, the problem involves coordination of the swallowing muscles in the mouth and throat; in others, there may be narrowing of the esophagus, a motility disorder, or reflux-related changes. This distinction requires both the diagnostic test and treatment to be selected individually.
Why are current methods in dysphagia diagnosis used together?
It is not always sufficient to evaluate swallowing difficulty with a single examination or imaging method. Even if the patient says “the food stays in my throat,” the problem may involve initiation of the swallowing reflex, food entering the laryngeal inlet, or the lower part of the esophagus. Especially in cases of aspiration where food silently enters the airway, the patient may not experience obvious coughing.
The current approach combines a detailed medical history and ENT examination with functional tests. The physician evaluates whether the complaint occurs with solid foods, liquids, or both; how long it has been present; and whether weight loss, voice changes, painful swallowing, or recurrent lung infections accompany it. Neurological diseases, previous head and neck surgery, radiotherapy, certain medications, and advanced age also influence the evaluation plan.
During clinical assessment, the movement of oral structures, tongue strength, palate function, cough strength, voice quality, and cranial nerve findings are examined. Water-swallow tests or standardized screening scales may be used when necessary. However, these steps do not definitively rule out aspiration. If suspicion continues, instrumental, meaning device-assisted, swallowing assessment is required.
Endoscopic swallowing evaluation: FEES
FEES stands for “Fiberoptic Endoscopic Evaluation of Swallowing.” A thin and flexible endoscope is advanced through the nose to visualize the nasopharynx, pharynx, and laryngeal region. While the patient swallows foods of different consistencies, the structures around the larynx, accumulation of secretions, food residue, and the risk of material entering the airway are evaluated.
One of the important advantages of FEES is that it does not involve radiation. Therefore, it can be repeated when necessary, performed at the bedside, and used with samples similar to the different consistencies the patient consumes in daily life. Being able to observe vocal cord movement, laryngeal sensation, and residue remaining in the throat after swallowing during the same session provides particularly valuable information in patients with both voice and swallowing complaints.
This method does not directly show the exact moment of swallowing because of a brief white-out in the image. It also provides limited information about the oral preparation phase and the lower part of the esophagus. Therefore, while FEES alone may be sufficient in some patients, in others it is complemented by videofluoroscopic examination or esophageal evaluation.
In which patients is FEES particularly useful?
People with neurological diseases, those who develop difficulty swallowing after a stroke, individuals who have received treatment for head and neck cancer, and older patients at risk of aspiration frequently benefit from FEES. Evaluation of laryngeal function is also important in people with prolonged hoarseness accompanied by a need to clear the throat, coughing while swallowing, or a sensation of something getting stuck in the larynx.
During the test, the question is not only “Is there aspiration?” It can also be observed whether compensatory methods such as changing head position, reducing bolus size, performing a double swallow, or modifying consistency are effective. This information helps personalize speech and swallowing therapy as well as nutritional recommendations.
Videofluoroscopic swallowing study
A videofluoroscopic swallowing study is also called a modified barium swallow test in some centers. While the patient swallows foods of different consistencies containing barium, moving X-ray images are obtained. In this way, many stages of swallowing can be dynamically observed, from lip closure and the tongue pushing food backward to pharyngeal contraction and opening of the upper esophageal sphincter.
This test is particularly useful for analyzing timing problems in the oral and pharyngeal phases, residue at the base of the tongue, movement of the pharyngeal walls, and passage through the upper esophagus. It can show in detail which consistency is safer, where food becomes stuck, and whether specific positions improve swallowing.
However, videofluoroscopy involves radiation and generally requires radiology facilities. Therefore, it does not have to be the first option for every patient. FEES may be more appropriate during pregnancy, when repeated testing is required, or when transporting the patient to the imaging unit is difficult. Rather than being alternatives to one another, the two methods are complementary examinations that answer different clinical questions.
Transnasal esophagoscopy and evaluation of the esophagus
The source of swallowing difficulty is not always the throat. In particular, solid foods becoming stuck, pressure behind the chest, failure of swallowing to progress, or reflux complaints may suggest an esophageal problem. In such cases, transnasal esophagoscopy may allow the upper digestive tract to be evaluated using a thin endoscope inserted through the nose.
Transnasal esophagoscopy is a method that can be performed in an office setting in suitable patients, often under local anesthesia. The nasal cavity, pharynx, larynx, and esophageal mucosa can be examined, providing information about narrowing, irritation, suspected masses, or structural changes. Whether the procedure is appropriate is determined by considering the patient’s medical condition, complaints, and expected diagnostic benefit.
In some patients, conventional upper gastrointestinal endoscopy, a contrast esophagram, or gastroenterological evaluation may be more appropriate. If a motility disorder of the esophageal muscles is suspected, high-resolution esophageal manometry may be considered; in reflux-related symptoms, pH-impedance testing may be appropriate. The aim is not to perform the same tests in everyone, but to follow the shortest and most reliable diagnostic pathway guided by the symptoms.
Which symptoms require prompt evaluation?
Newly developed and progressively worsening difficulty swallowing should always be evaluated. However, some symptoms require more rapid investigation: unintentional weight loss, painful swallowing, inability to swallow even saliva, recurrent pneumonia, bloody sputum or vomiting, a neck mass, persistent voice changes, and progressive shortness of breath are among them.
In children, prolonged feeding time, frequent choking sensations, refusal of meals, impaired growth and development, recurrent lung infections, or a wet-gurgly voice should be evaluated carefully. Because children may express their symptoms differently from adults, family observations are highly valuable in the diagnostic process.
The point at which diagnostic results guide treatment
Dysphagia treatment is planned according to the cause identified by the tests. In some patients, swallowing therapy, posture adjustments, and consistency modifications may be sufficient. Reflux, infection, or neurological causes may require medical treatment and collaboration with relevant specialties. Structural narrowing, diverticula, vocal cord movement disorders, or selected esophageal problems may require endoscopic or surgical options.
As in Prof. Dr. Elif Aksoy’s approach, the value of advanced swallowing evaluation is not simply to produce a test report. The goal is to clearly explain why the patient is having difficulty, protect the airway, and create a safe and sustainable nutritional plan for daily life. If difficulty swallowing has been present for a long time or is affecting your quality of life, choosing the right specialist and the appropriate test is one of the most important steps in reducing uncertainty.
