European Journal of Cardiovascular Medicine

Deglutition is a highly coordinated sensorimotor act in which food is prepared in the oral cavity, propelled through the pharynx and transported through the oesophagus into the stomach, under the control of the brainstem swallowing centre, several cranial nerves and numerous striated and smooth muscles [1, 2]. Dysphagia, or difficulty in swallowing, is therefore a symptom rather than a diagnosis; it may signal disease anywhere from the oral cavity to the gastro-oesophageal junction, as well as disorders of the central and peripheral nervous system and of the swallowing musculature [1, 3]. Because many of the structures involved lie within the domain of the otolaryngologist, dysphagia is among the commonest complaints encountered in ENT practice.

Swallowing difficulty is far from rare in the community. Population surveys have documented swallowing complaints in a substantial proportion of middle-aged and older adults [4], and a national survey in the United States estimated that about 4% of adults had experienced a swallowing problem in the preceding year [5]. Community and primary care studies likewise show that the prevalence rises with advancing age and is frequently under-reported [6, 7]. The consequences are not trivial. Dysphagia predisposes to malnutrition, dehydration and aspiration pneumonia [8, 9], and it carries a considerable social and psychological burden for patients and families [10].

The etiological spectrum of dysphagia differs between regions and between clinical settings, depending on the prevalence of risk factors, the pattern of referral and the facilities available. In India, much of the available literature on dysphagia comes from gastroenterology and surgical endoscopy units and concentrates on oesophageal causes [11, 12]. Reports from otolaryngology departments are fewer; one such prospective series from central India examined the correlation of radiological and endoscopic findings in patients presenting with dysphagia [13]. This gap is important because India carries a heavy burden of head and neck cancer, driven largely by smoked and smokeless tobacco, areca nut and alcohol [14, 15]. Nearly one-third of Indian adults use tobacco in some form [16], and smokeless tobacco use in particular is widespread [17]. Oropharyngeal and hypopharyngeal malignancies commonly present with dysphagia as an early or even the sole symptom, and are frequently diagnosed late.

At the same time, other conditions are on the rise or remain prevalent in the Indian setting, including gastro-oesophageal and laryngopharyngeal reflux [18], stroke-related neurogenic dysphagia [19], accidental foreign body impaction and corrosive ingestion. The ENT outpatient department (OPD) is often the first point of contact for such patients, and a structured assessment at this level can shorten the time to diagnosis, guide appropriate referral and prevent complications. Despite this, systematic descriptions of the clinical profile and etiology of dysphagia in the ENT OPD of a tertiary care teaching hospital are limited. The present study was undertaken to fill this gap.

AIMS AND OBJECTIVES

Primary objective: To study the clinical profile of patients presenting with dysphagia to the ENT outpatient department of a tertiary care teaching hospital.

Secondary objectives: (1) To determine the etiological spectrum of dysphagia; (2) to assess the association of selected demographic and lifestyle risk factors with malignant etiology; (3) to document the diagnostic yield of the investigations used; and (4) to record the management offered and the complications encountered.

Study design, setting and duration

This was a hospital-based, prospective, observational study conducted in the Department of Otorhinolaryngology and Head & Neck Surgery of a tertiary care teaching hospital over a period of 12 months (January 2019 to December 2019). Patients attending the ENT OPD, either directly or on referral from other departments, were screened for eligibility.

Ethical considerations

The study was approved by the Institutional Ethics Committee before commencement. Written informed consent was obtained from all participants (or from a parent or legal guardian for patients under 18 years), and the study was conducted in accordance with the Declaration of Helsinki and the national ethical guidelines for biomedical and health research involving human participants [20]. Confidentiality of patient data was maintained throughout.

Sample size and sampling

The sample size was calculated using the formula n = Z²pq/d², taking a 95% confidence level (Z = 1.96), an expected proportion of malignant etiology (p) of 35% and an absolute precision (d) of 6.6%, which gave a minimum sample of approximately 200 patients. Consecutive eligible patients were enrolled until this number was reached. Of 226 patients who presented with dysphagia during the study period, 26 were excluded (12 unwilling to participate, 8 below 10 years of age and 6 haemodynamically unstable at presentation), leaving 200 for analysis.

Inclusion and exclusion criteria

Inclusion criteria: patients aged 10 years or above, of either sex, presenting with difficulty in swallowing of at least two weeks’ duration and willing to give informed consent.

Exclusion criteria: patients below 10 years of age, those who were haemodynamically unstable or required emergency intensive care at presentation, and those unwilling to participate.

Data collection and clinical evaluation

Data were recorded on a pre-designed, pre-tested proforma. The history included age, sex, place of residence, tobacco use (smoked and smokeless), alcohol use, comorbidities, and the duration, mode of onset, progression and site of dysphagia, the consistency of food affected (solids, liquids or both) and associated symptoms such as odynophagia, weight loss, hoarseness, regurgitation, cough or choking during swallowing, heartburn, globus sensation, neck swelling and referred otalgia. General examination included pallor, nutritional status (body mass index, BMI) and hydration. This was followed by a complete ENT examination of the oral cavity, oropharynx and neck, indirect laryngoscopy and flexible nasopharyngolaryngoscopy (FNL) in every patient, along with cranial nerve and basic neurological examination.

Investigations

Haemoglobin, complete blood count and random blood glucose were obtained in all patients. Further investigations were selected according to the clinical localisation of the lesion. Barium swallow was performed when a hypopharyngeal or oesophageal lesion was suspected (videofluoroscopy was not available in our institution). Upper gastrointestinal endoscopy (UGIE) was carried out in collaboration with the Department of Gastroenterology, and reflux oesophagitis was graded by the Los Angeles classification [21]. Laryngopharyngeal reflux was assessed with the Reflux Symptom Index and the Reflux Finding Score [22, 23]. Biopsy under direct laryngoscopy or oesophagoscopy and fine needle aspiration cytology (FNAC) were performed for suspicious lesions and neck masses. Contrast-enhanced computed tomography (CECT) of the neck and thorax, ultrasonography of the neck and magnetic resonance imaging (MRI) of the brain were obtained where indicated. Flexible endoscopic evaluation of swallowing (FEES) [24] was performed in patients with suspected aspiration, neurological or post-treatment dysphagia, and the penetration–aspiration scale was used to grade findings [25]. Oesophageal manometry, interpreted according to the Chicago Classification [26], was done in patients with suspected motility disorders.

Classification of etiology and outcome measures

Patients were assigned a final diagnosis on the basis of the combined clinical, endoscopic, radiological and histopathological findings. Etiologies were grouped into ten categories: malignant, inflammatory/infective, reflux-related, neurological/neuromuscular, foreign body/corrosive, structural (benign), iatrogenic (post-treatment), extrinsic compression, functional, and others. Dysphagia was also classified by the site of dysfunction as oropharyngeal, oesophageal or functional/indeterminate. Management offered, nutritional support, complications and in-hospital outcome were recorded, and patients were followed up for a minimum of four weeks.

Statistical analysis

Data were entered in Microsoft Excel and analysed with IBM SPSS Statistics version 26. Categorical variables are presented as frequencies and percentages, and continuous variables as mean ± standard deviation (SD). The chi-square test (or Fisher’s exact test where expected cell counts were below five) was used to compare proportions, and one-way analysis of variance (ANOVA) to compare means across groups. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for risk factors. A two-tailed p-value of less than 0.05 was considered statistically significant.

Demographic profile

A total of 200 patients with dysphagia were included. Their ages ranged from 11 to 86 years (mean 51.0 ± 16.2 years; median 52 years), and 114 patients (57.0%) were 50 years of age or older. The highest number of patients (52; 26.0%) belonged to the 51–60-year age group, followed by 41–50 years (20.0%) and 61–70 years (19.0%) (Table 1). There were 122 males (61.0%) and 78 females (39.0%), a male-to-female ratio of 1.56:1; males outnumbered females in every age group.

Table 1: Age and sex distribution of the study population (N = 200)

Mean age 51.0 ± 16.2 years; range 11–86 years. Percentages in the last column are calculated on the total sample.

Most patients (118; 59.0%) came from rural areas. Tobacco use in any form was documented in 126 patients (63.0%): 74 (37.0%) smoked and 68 (34.0%) used smokeless tobacco, of whom 16 used both. Alcohol use was reported by 62 patients (31.0%). Hypertension (29.0%) and diabetes mellitus (23.0%) were the commonest comorbidities (Table 2).

Table 2: Residence, personal habits and comorbidities (N = 200)

Tobacco and comorbidity categories are not mutually exclusive where indicated.

Clinical features

The commonest duration of symptoms was 1–3 months (31.0%), and 26.0% of patients had symptoms for more than six months at presentation. Onset was gradual in 172 patients (86.0%) and sudden in 28 (14.0%). The course was progressive in 118 patients (59.0%), intermittent in 52 (26.0%) and static in 30 (15.0%). Difficulty with solids alone was reported by 98 patients (49.0%), with both solids and liquids by 84 (42.0%) and with liquids alone by 18 (9.0%). On clinical localisation, 112 patients (56.0%) had oropharyngeal dysphagia, 74 (37.0%) had oesophageal dysphagia and in 14 (7.0%) the dysphagia was functional or could not be localised (Table 3).

Table 3: Characteristics of dysphagia (N = 200)

Percentages are calculated on N = 200 within each characteristic.

Odynophagia was the most frequent associated symptom (48.0%), followed by weight loss (44.0%), hoarseness of voice (32.0%), cough or choking during swallowing (29.0%) and heartburn or acid brash (29.0%). Referred otalgia was present in 14.0% and blood-stained saliva in 7.0% (Table 4).

Table 4: Associated symptoms (multiple responses; N = 200)

A patient could report more than one symptom.

On examination, pooling of saliva in the vallecula or pyriform fossae was the commonest finding (26.0%), followed by laryngeal changes suggestive of reflux (Reflux Finding Score > 7; 27.0%) and a mass or growth in the hypopharynx, larynx or base of tongue on endoscopy (23.0%). Cervical lymphadenopathy was noted in 23.0% and pallor in 19.0%. Vocal cord palsy was found in 22 patients (11.0%) and a neurological deficit in 26 (13.0%). In 20 patients (10.0%) no abnormality was detected on ENT examination (Table 5).

Table 5: Clinical examination findings (multiple responses; N = 200)

RFS: Reflux Finding Score.

Investigations

Flexible nasopharyngolaryngoscopy and haemoglobin estimation were done in all 200 patients. Barium swallow was performed in 112 patients (56.0%), UGIE in 92 (46.0%), biopsy or histopathological examination in 68 (34.0%) and CECT neck and thorax in 64 (32.0%). FEES was carried out in 56 patients (28.0%); penetration or aspiration was seen in 31 of these (55.4%), including silent aspiration in 14 (25.0%). Anaemia (haemoglobin < 13 g/dL in men and < 12 g/dL in women) was present in 62 patients (31.0%) (Table 6).

Table 6: Investigations performed (N = 200)

CECT: contrast-enhanced computed tomography; FNAC: fine needle aspiration cytology; GA: general anaesthesia.

Barium swallow was normal in 24 of 112 patients (21.4%); the commonest abnormality was a filling defect or irregular narrowing (33.9%), followed by pooling or residue in the vallecula or pyriform fossae (17.0%). On UGIE, 40 of 92 patients (43.5%) had a normal study, 18 (19.6%) had reflux oesophagitis and 14 (15.2%) had a growth (Table 7). Histopathology in 68 patients showed squamous cell carcinoma in 49 (72.1%), of which 24 were moderately differentiated, 15 well differentiated and 10 poorly differentiated; two adenocarcinomas, three granulomatous (tuberculous) lesions and two benign lesions were also identified (Table 8).

Table 7: Findings on barium swallow and upper gastrointestinal endoscopy

LA: Los Angeles classification. Percentages are calculated on the number of patients investigated by each modality.

Table 8: Histopathological findings (n = 68)

Three papillary carcinomas of the thyroid were diagnosed by FNAC and are not included in this table.

Etiological profile

A definite etiology was established in all 200 patients. Malignancy was the commonest cause (54 patients; 27.0%), followed by inflammatory/infective conditions (32; 16.0%), reflux-related disease (28; 14.0%), neurological or neuromuscular disorders (20; 10.0%) and foreign body or corrosive injury (16; 8.0%). Benign etiologies together accounted for 146 patients (73.0%) (Table 9, Figure 1). Among the 54 malignancies, the hypopharynx was the commonest primary site (22; 40.7%), followed by the oropharynx (12; 22.2%), oesophagus (10; 18.5%), larynx (7; 13.0%) and thyroid (3; 5.6%); squamous cell carcinoma constituted 49 (90.7%) of these. Stroke was the leading neurological cause (11 of 20 patients), and impacted foreign bodies the commonest cause in the foreign body/corrosive group (13 of 16 patients).

Table 9: Etiological profile of dysphagia (N = 200)

Percentages are calculated on the total sample (N = 200).

The mean age differed significantly across etiological groups (one-way ANOVA, p < 0.001): it was highest in patients with neurological causes (66.4 ± 11.8 years) and malignancy (61.8 ± 9.6 years) and lowest in the inflammatory/infective group (35.4 ± 17.2 years) and functional dysphagia (38.2 ± 10.5 years). Patients with malignancy were on average 14.7 years older than those with benign causes (61.8 vs 47.1 years). Males predominated in malignant (70.4%), neurological (70.0%) and iatrogenic (75.0%) groups, whereas females predominated in the functional and extrinsic compression groups (Table 10).

Table 10: Etiological groups by sex and mean age

One-way ANOVA for difference in mean age across groups: p < 0.001.

Risk factors for malignant etiology

Tobacco use in any form was documented in 48 of 54 patients with malignancy (88.9%) compared with 78 of 146 patients with benign causes (53.4%) (OR 6.97; 95% CI 2.81–17.3; p < 0.001). Alcohol use was likewise more frequent in the malignant group (55.6% vs 21.9%; OR 4.45; 95% CI 2.29–8.65; p < 0.001), as was age of 50 years or above (85.2% vs 46.6%; OR 6.60; 95% CI 2.91–14.95; p < 0.001). Male sex was more common among patients with malignancy (70.4% vs 57.5%), but this difference was not statistically significant (p = 0.098) (Table 11).

Table 11: Association of risk factors with malignant etiology

Chi-square test; OR: odds ratio; CI: confidence interval. A p-value < 0.05 was considered significant.

Management, complications and outcome

Medical therapy (proton pump inhibitors, prokinetics, antibiotics, antifungals, steroids and haematinic supplementation) was the primary treatment in 66 patients (33.0%), endoscopic or surgical intervention in 46 (23.0%), and referral for oncological management in 54 (27.0%), curative-intent in 34 of the latter and palliative in 20. Swallowing rehabilitation, diet modification, counselling and neurological referral were the mainstay in 34 patients (17.0%). Endoscopic or surgical procedures comprised foreign body removal (13), incision and drainage of abscess (8), oesophageal dilatation (9), cricopharyngeal myotomy or pouch surgery (4), thyroidectomy (5), pneumatic dilatation or referral for myotomy in achalasia (4), excision of benign lesions (2) and cervical osteophytectomy (1). Nasogastric (Ryle’s) tube feeding was needed in 38 patients (19.0%), gastrostomy in 8 (4.0%) and tracheostomy for airway compromise in 6 (3.0%) (Table 12).

Table 12: Management of the study population (N = 200)

Oncological referral: 34 patients curative-intent (surgery and/or chemoradiotherapy), 20 palliative.

By BMI, 52 patients (26.0%) were underweight (< 18.5 kg/m²). Dehydration was present in 24 patients (12.0%) and aspiration pneumonia developed in 18 (9.0%). Four patients (2.0%) died during hospital stay or follow-up: three with advanced malignancy and one with aspiration pneumonia following stroke. At four weeks, 121 of 146 patients with benign etiology (82.9%) had complete or marked relief of dysphagia, whereas 25 (17.1%), mainly those with neurological or post-radiotherapy causes, had persistent or partial symptoms (Table 13).

Table 13: Nutritional status, complications and outcome (N = 200)

Percentage for the last row is calculated on the 146 patients with benign etiology

Dysphagia is a symptom with a remarkably wide differential diagnosis, and its evaluation in the ENT OPD requires the clinician to think across the oral cavity, pharynx, larynx, oesophagus and nervous system [3, 27]. In this prospective study of 200 patients, malignancy emerged as the single largest cause (27.0%), with the hypopharynx the commonest primary site, whereas benign conditions collectively accounted for nearly three-quarters of the cases. Tobacco and alcohol use were strongly associated with malignant etiology, and a considerable proportion of patients presented with malnutrition or complications of aspiration.

The mean age of 51.0 years, with a peak in the sixth decade, is in keeping with the general observation that dysphagia becomes more frequent with advancing age [4, 6]. A prospective ENT-department series from central India reported a mean age of 48.3 ± 20.3 years and a male-to-female ratio of 2.33:1 [13], which is broadly similar to our mean age but with a somewhat stronger male preponderance than our ratio of 1.56:1. The male predominance in our series was driven largely by the malignant group (70.4% males), consistent with the higher prevalence of tobacco and alcohol use among Indian men [16]. Differences in sex ratio between Indian series probably reflect differences in referral patterns, the proportion of malignant cases and local habits. Older age in the elderly is not merely a demographic observation; age-related changes in swallowing physiology and a higher burden of neurological disease make older patients especially vulnerable to nutritional and respiratory complications [8].

Nearly 60% of our patients lived in rural areas and 63.0% used tobacco in some form, with smokeless tobacco use nearly as frequent as smoking. This mirrors national data showing that roughly one-third of Indian adults use tobacco [16] and that chewed and other smokeless forms are deeply entrenched in many communities [17]. Rural predominance probably also reflects the catchment of a tertiary teaching hospital that serves a largely agrarian population, with

limited access to primary-level screening. The Kerala oral visual screening trial showed that screening can reduce oral cancer mortality in high-risk tobacco and alcohol users [28], which underlines the potential value of early referral of any person with persistent swallowing difficulty in this population.

The great majority of our patients had gradual onset (86.0%) and almost 60% had a progressive course, a pattern typical of neoplastic and stricturing disease, whereas sudden onset (14.0%) was largely explained by foreign body impaction, stroke and acute infections. Difficulty confined to solids in 49.0% points to mechanical obstruction, while involvement of both solids and liquids, or of liquids alone, should prompt consideration of neuromuscular or motility disorders [1, 3]. Odynophagia, weight loss, hoarseness and referred otalgia were frequent and, in an adult tobacco user, should be regarded as alarm features. Referred otalgia, present in 14.0% of our patients, is transmitted through the glossopharyngeal and vagus nerves and often points to a hypopharyngeal or base-of-tongue lesion. Anaemia was found in 31.0% of patients; apart from chronic blood loss and malignancy, iron deficiency may be associated with post-cricoid web formation (Plummer–Vinson syndrome), a classical but now less frequent cause of dysphagia [29]. Weight loss in 44.0% and a BMI below 18.5 kg/m² in 26.0% show how early malnutrition sets in, which has direct implications for treatment tolerance and survival [30].

Malignancy was the leading etiology in our series (27.0%), and squamous cell carcinoma accounted for 90.7% of these tumours. This proportion is high but not surprising for an ENT OPD in a country where head and neck and upper aerodigestive tract cancers are among the commonest malignancies [14, 15]. Regional Indian epidemiological work on head and neck malignancies likewise documents a predominance of tobacco-related squamous cell carcinoma [31]. The Jabalpur ENT series concluded that males are more commonly affected than females and that the incidence of malignancy increases with age [13]; our patients with malignancy were on average about 15 years older than those with benign disease, and age of 50 years or above was strongly associated with malignant etiology (OR 6.60). The odds of malignancy were almost sevenfold higher in tobacco users (OR 6.97) and more than fourfold higher in alcohol users (OR 4.45), in agreement with the pooled international data that show a strong, interacting effect of tobacco and alcohol on head and neck cancer risk [32]. Oesophageal carcinoma formed only 5.0% of our cases, which is expected because most oesophageal cancers are evaluated in gastroenterology and surgical oncology units, where they account for a larger proportion of dysphagia [11, 12]. Oesophageal squamous cell carcinoma remains particularly common in certain parts of India such as the Kashmir valley [33] and has a poor prognosis when diagnosed late [34].

Reflux disease accounted for 14.0% of our patients, with laryngopharyngeal reflux (LPR) predominating. LPR is a recognised cause of globus, throat discomfort, hoarseness and dysphagia, and its laryngeal signs are best captured by structured scoring systems [23, 35]. Gastro-oesophageal reflux, once considered uncommon in India, is now recognised to be prevalent across the country [18], and the finding that 19.6% of the patients who underwent UGIE had reflux oesophagitis supports this. A trial of acid suppression with lifestyle modification is therefore reasonable in patients with typical features and no alarm symptoms, provided malignancy has been excluded by endoscopic examination.

Neurological and neuromuscular disorders caused dysphagia in 10.0% of our patients, and stroke accounted for more than half of them. Dysphagia is very common after stroke and carries a high risk of pulmonary complications [36], and it is also frequent in Parkinson’s disease and other neurodegenerative conditions [37, 38]. Given the large and growing burden of stroke in India [19], ENT surgeons will increasingly be asked to evaluate swallowing in these patients. In our series FEES revealed penetration or aspiration in 55.4% of those assessed and silent aspiration in 25.0%, a finding that cannot be detected reliably at the bedside and which is a recognised precursor of aspiration pneumonia [9, 24]. Aspiration pneumonia developed in 9.0% of our patients, underscoring the need for early instrumental assessment, safe-swallow strategies and, where necessary, alternative feeding.

Inflammatory and infective conditions formed the second-largest group (16.0%) and were largely acute: tonsillitis and pharyngitis, peritonsillar and deep neck space abscesses and acute supraglottitis. These patients were younger (mean age 35.4 years) and responded well to antibiotics, drainage or airway protection. Pharyngeal candidiasis, seen mainly in diabetic patients and those on inhaled or systemic steroids, and tuberculosis of the pharynx and larynx, which remains relevant in a country with a high tuberculosis burden, are important to recognise because they are readily treatable but may mimic malignancy.

Impacted foreign bodies and food boluses accounted for 6.5% and corrosive strictures for 1.5% of our patients. Prompt endoscopic removal prevents complications such as perforation, abscess and mediastinitis [39, 40]. Indian endoscopic series have studied the clinical and endoscopic profile of benign oesophageal strictures and have demonstrated that outpatient dilatation can be performed safely and effectively [41–43]. In our setting, strictures were managed jointly with gastroenterology colleagues using serial dilatation.

Pharyngeal pouch, cricopharyngeal dysfunction, anterior cervical osteophytes, post-cricoid web and benign tumours together accounted for 7.0% of cases. Such conditions are easily missed unless a barium study or endoscopy is performed, and several are amenable to endoscopic or open surgical treatment [44]. Achalasia, though not an ENT disease, was found in five patients and diagnosis was supported by barium swallow and manometry interpreted according to the Chicago Classification [26]. Functional dysphagia or globus accounted for 7.0% of our patients and is a diagnosis of exclusion; after structural, reflux-related and neurological causes have been reasonably excluded, reassurance and treatment of any coexisting reflux are usually sufficient [45].

Flexible nasopharyngolaryngoscopy was done in every patient and was the pivotal investigation for hypopharyngeal, laryngeal and base-of-tongue disease. The Jabalpur study found endoscopy to be the most sensitive test (98.75%), compared with CT (85.7%) and barium swallow (49.05%), and recommended endoscopy as the first screening test with radiology as an adjunct [13]. In our series barium swallow was normal in 21.4% of patients and a normal study should never be taken to exclude mucosal disease. FEES offers the otolaryngologist a bedside, radiation-free means of assessing swallowing safety [24]. A pragmatic, stepwise approach – history, ENT examination, flexible endoscopy, then barium swallow, UGIE, imaging or manometry guided by the likely site of pathology – allowed a definite etiology to be established in all our patients.

Treatment of dysphagia is cause-specific, but common principles apply: correction of nutritional and fluid deficits, protection of the airway and early involvement of speech-language pathologists and dieticians [8, 30]. In our study, 19.0% of patients required nasogastric feeding and 4.0% gastrostomy, and 82.9% of those with benign causes had marked relief at four weeks. The persistence of symptoms in neurological and post-radiotherapy patients highlights the need for longer-term rehabilitation. Because dysphagia also carries a significant psychosocial burden [10], counselling of patients and caregivers should form part of routine care.

STRENGTHS AND LIMITATIONS

The strengths of this study include its prospective design, consecutive enrolment, uniform protocol-based evaluation of every patient with flexible endoscopy, and the use of validated tools for reflux assessment and for grading aspiration. The limitations are that it was a single-centre study at a tertiary referral hospital, so referral bias may have over-represented advanced malignancy and complex cases; videofluoroscopy, high-resolution manometry and pH-impedance monitoring were not uniformly available; validated dysphagia severity and quality-of-life scores were not used; and follow-up was limited to four weeks. Multicentre studies with longer follow-up are needed to confirm these findings.

Dysphagia in the ENT OPD has a diverse etiology. Malignancy, predominantly tobacco- and alcohol-related carcinoma of the hypopharynx and oropharynx in older men, was the single largest cause (27.0%), but nearly three-quarters of patients had benign and often treatable conditions such as infections, reflux-related disease, foreign bodies and structural lesions. Gradual progressive dysphagia, odynophagia, weight loss, hoarseness and referred otalgia should raise suspicion of malignancy, particularly in tobacco and alcohol users aged 50 years or above, and warrant early flexible endoscopy and biopsy. Neurological dysphagia carries a high risk of silent aspiration and calls for instrumental assessment. A structured stepwise work-up, early nutritional support and a multidisciplinary approach can reduce diagnostic delay, malnutrition and aspiration-related morbidity, while community-level tobacco and alcohol control remains the most effective long-term preventive strategy.

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