Management of oropharyngeal dysphagia often involves a polydisciplinary evaluation, the aims of which are to identify and characterize oropharyngeal dysphagia and identify the underlying cause whenever possible. Specific diagnosis of the underlying cause of neurogenic dysphagia is rarely made on the basis of videoradiographic or manometric observations because observed patterns of oral, laryngeal, pharyngeal, and cricopharyngeal dysfunction can exist in a range of neurogenic disorders. Finding the underlying cause of oropharyngeal dysphagia often requires that the clinical team think broadly because of the wide array of diagnostic possibilities. Special emphasis should be placed on detection of treatable underlying systemic conditions such as thyrotoxicosis, myopathy, myasthenia, and neoplasms. Similarly, when neuromuscular disease is suspected, appropriate imaging (computed tomography, magnetic resonance imaging), function tests (EMG, nerve conductance, Tensilon test), histological examinations (mucosal or muscle biopsy), or serological tests (CPK level, antinuclear antibody level, anticholinesterase antibody level, lumbar puncture) should be obtained. While seeking evidence for a systemic disorder, the second aim of clinical evaluation is to identify surgically (or endoscopically) treatable structural abnormalities. Careful radiographic and/or endoscopic examination of the oropharynx and proximal esophagus is aimed at detecting signs of neoplasm, infection, strictures, or diverticuli, each of which implies a specific therapy. Even when effective therapy does not exist for the underlying condition, it is a firmly held conviction among practitioners, and an expectation among patients, that accurate determination of diagnosis and prognosis is an important medical goal. After important etiological abnormalities have been sought, functional abnormalities of oropharyngeal swallowing should be defined. In some instances, endoscopic examination of the oropharynx may suggest the main abnormality of the swallow, but characterization of the temporal disruption of swallowing coordination and identification of the underlying mechanism leading to that dysfunction require videofluoroscopic or cineradiographic examination. In some instances, especially with suspected UES dysfunction, concurrent use of pharyngeal manometry with videofluoroscopy can allow further delineation of the underlying pathology and direct treatment. From this point on, management decisions will be applicable to those patients in whom a structural, surgically treatable abnormality has been excluded. When considering further treatment strategies, the clinician must first establish whether institution of normal (e.g., gastrostomy) feeding is indicated. This will depend on establishing the likelihood that the patients will be able to sustain adequate nutrition safely via the oral route and on the unproven but reasonable premise that nonoral feeding is likely to reduce the risk of aspiration pneumonia. This decision is made in conjunction with the speech language pathologist who can, on the basis of videofluoroscopic analysis of therapeutic maneuvers, estimate the likelihood that such maneuvers will reduce the risks of oral feeding and enhance the efficiency of swallowing. The natural history and prognosis of the underlying cause of dysphagia, as well as the patient's cognitive ability, will also influence the choice between oral and nonoral feeding. Introduction of appropriate dietary modification and specific swallowing therapy by the speech language pathologist is appropriate at this point. The choices among therapies will be directed by the videofluoroscopic findings and the individual patient's ability to comprehend and cooperate with the various strategies. This process will frequently involve a subsequent videofluoroscopic examination to assess progress and the advisability of ongoing swallowing therapy and ascertain whether alternatives should be considered. The place of cricopharyngeal myotomy and other procedures such as laryngeal suspension in this class of patient remains controversial. The clinician can predict an overall response rate for myotomy of approximately 60% but at present cannot predict with certainty the likelihood of response in an individual patient. Until further well-designed studies in clearly defined subsets of patients are conducted, the decision about myotomy will remain empirical after the patient is informed of the risks and possible, but unproven, benefits. Management of oropharyngeal dysphagia is currently an inexact science. The quality of evidence supporting much of what is generally accepted as current best practice is not high but is backed by reasonable evidence of biological plausibility and weight of clinical opinion. However, it is the responsibility of the professional groups involved in the care of these patients to undertake studies that examine rigorously the efficacy of current and future therapies, both medical and surgical, and the diagnostic and predictive utility of tools for the measurement of swallowing mechanics and dysfunction.
