Esophageal Dysphagia in Focus: Recognizing What’s Often Overlooked

When a patient reports difficulty swallowing, speech-language pathologists (SLPs) are often the first clinicians called upon to evaluate the problem. Traditionally, that evaluation has focused on the oropharyngeal phases of swallowing, while esophageal concerns were left to gastroenterology.

But we now know that swallowing isn’t a series of separate events—it’s a continuum. What happens in the esophagus influences, and is influenced by, what happens in the pharynx. Overlooking that connection can lead to incomplete assessments, missed diagnoses, and treatment plans that don’t fully address the patient’s needs.

In this article, we’ll take a closer look at esophageal dysphagia: why it matters for your clinical practice, how you can begin to identify it during patient interviews and assessments, and a real-world case that shows just how easy it is to miss if you stop at the oropharyngeal level.

Why SLPs should care about the esophagus

For decades, dysphagia management operated in silos. SLPs were expected to focus on the oropharyngeal swallow, while gastroenterologists evaluated the esophageal phase. Limited interdisciplinary education, conflicting guidelines, and traditional role boundaries reinforced this divide.

But growing evidence, and what you’ve probably seen in practice, makes it clear why SLPs need to develop working knowledge of the esophagus:

• Patients misidentify symptoms. Many describe food “sticking in the throat,” when the actual problem lies further down in the mid or distal esophagus.

• Multidomain involvement is common. Conditions like Parkinson disease, Huntington’s disease, and autoimmune disorders often present with both pharyngeal and esophageal findings.

• Disorders are reciprocal. Strategies you use to support oropharyngeal swallowing can also influence esophageal clearance—sometimes for better, sometimes for worse.

• Professional standards are evolving. ASHA’s Dysphagia Competency Verification Tool now specifies that SLPs should be able to describe suspected esophageal abnormalities during swallow evaluations, even if the final diagnostic statement comes from the radiologist.

In fact, experts have long emphasized that pharyngeal and esophageal disorders frequently occur together, and that clinicians should examine the entire swallow chain in patients with dysphagia.¹ Ignoring the esophageal phase risks missing part of the patient’s story—and with it, the chance to make your assessment and treatment truly comprehensive.

Case study: When Parkinson disease masks esophageal dysphagia 

Let’s look at a case from my clinic that illustrates how easily an esophageal disorder can go undetected without a comprehensive assessment.

Patient history

An 85-year-old gentleman was referred to me after his primary care physician noted “dysphagia to solids and liquids.” His medical history was significant: diabetes, COPD, hypertension, coronary artery disease with a pacemaker, and Parkinson disease diagnosed about 15 years earlier. He had also experienced a possible transient ischemic attack and had been hospitalized with aspiration pneumonia three times in the past two years.

When I interviewed him, he described a new onset of dysphagia for both solids and liquids over the past two years, with gradual progression. He reported coughing both with and without eating, food “hanging low in the throat,” frequent regurgitation, a sore throat in the morning, and a 25-pound weight loss over six months. He casually added, “I used to get my throat dilated,” though he couldn’t remember when or why.

Initial evaluation

I began with a modified barium swallow study (MBSS). On the surface, his oropharyngeal swallow looked functional. He had good oral preparation, adequate pharyngeal constriction, minimal residue, and no aspiration. This was not what I expected in someone with multiple episodes of aspiration pneumonia.

Esophageal screening

At our Swallow Center, we always include an esophageal screen at the end of the MBSS. In his case, the findings were striking. During liquid swallows, I observed significant bolus hang-up in the esophagus, with back-and-forth movement and poor clearance. That raised my suspicion of an esophageal component to his dysphagia.

Follow-up testing

I referred him to our gastroenterology colleagues for additional evaluation. Two tests were especially telling:

• Timed barium esophagram: At five minutes, a large column of barium remained in the esophagus, confirming poor emptying.

• High-resolution esophageal manometry (HREM): This revealed high resting pressure at the lower esophageal sphincter (LES), incomplete relaxation, and panesophageal pressurization—the classic pattern of achalasia.

The final diagnosis was co-occurring Parkinson disease and achalasia. Achalasia is a rare motility disorder where the lower esophageal sphincter (LES) does not relax properly and the esophageal muscles lose their coordinated peristalsis.

Interestingly, Parkinson disease affects not only motor function but also the enteric nervous system, where abnormal protein buildup is found in the nerves of the GI tract, impacting a range of GI functions. 

Achalasia likewise results from disruption of the enteric nervous system, in which impaired signaling prevents proper contraction and sphincter relaxation. The co-occurrence of Parkinson disease and achalasia may therefore stem from shared neurodegenerative mechanisms affecting both central and enteric nervous systems, suggesting a possible pathological link between the two conditions.²

Clinical lessons

From this case, there are several key lessons you can apply to your own practice:

• Patient reports can be misleading. Many patients localize symptoms to the throat when the actual issue lies lower in the esophagus.

• Normal oropharyngeal findings don’t rule out dysphagia. Always consider whether symptoms point to an esophageal contribution.

• Esophageal screening is invaluable. Adding it to the MBSS can reveal retention, poor clearance, or abnormal motility, which explains persistent symptoms.

• Referrals are essential. Knowing when to involve gastroenterology and order tests such as a timed barium esophagram or esophageal manometry ensures your patients receive accurate diagnoses and appropriate dysphagia treatment.

For this gentleman, that esophageal screen completely changed the direction of care. Instead of assuming his dysphagia was “part of Parkinson disease,” we uncovered a second, treatable condition that had been overlooked for years.

Clinical interviewing and assessment

The case illustrates how critical it is to go beyond the oropharynx and think comprehensively about assessment. Even if you aren’t the one performing advanced esophageal testing, you need to know what patterns to look for and when to make a referral.

History-taking clues

When you sit down with a patient, the questions you ask can uncover valuable information. Start with:

• Is the dysphagia acute, intermittent, or progressive? Acute onset may suggest inflammation or obstruction, while progressive symptoms point toward motility disorders or stricture.

• Does it occur with solids, liquids, or both? Solids-only dysphagia is more consistent with obstruction; both solids and liquids suggest motility issues.

• Does the sensation occur immediately during the swallow, or a few seconds after? Immediate obstruction often indicates narrowing, and delayed symptoms may signal impaired esophageal peristalsis. 

Even when patients mislocalize their symptoms, structured questioning helps you identify patterns that guide your diagnostic decisions.

Oropharyngeal vs. esophageal symptoms

Distinguishing between oropharyngeal and esophageal dysphagia is one of the most useful skills you can develop in practice.

If a patient reports coughing during the swallow, you’re likely dealing with oropharyngeal involvement. If they describe regurgitation or slow passage through the chest, esophageal dysphagia should be on your radar.

Instrumental assessments

You may not perform every esophageal test yourself, but knowing what they measure strengthens your role on the interdisciplinary team.

• Barium swallow test (esophagus): Offers a broad look at anatomy, motility, reflux, and clearance. It’s inexpensive and accessible, though less detailed for the pharyngeal phase.³

• Esophageal manometry: The gold standard for motility assessment. Measures pressures, peristalsis, and LES/UES relaxation, often ordered before anti-reflux surgery or when patients present with unexplained chest pain.⁴

• Endoscopy (EGD): Excellent for visualizing mucosal detail, strictures, or tumors, but limited in its ability to assess motility.

When you understand what these tests can (and can’t) tell you, you’re in a better position to make informed referrals, interpret results in the context of your swallow evaluations, and integrate findings into care planning.

Expanding your role in dysphagia care

Recognizing esophageal involvement isn’t about stepping outside your scope—it’s about making your work more accurate, collaborative, and impactful. Here’s how that plays out in practice:

• You don’t need to perform every test. However, you need to recognize when symptoms point beyond the oropharynx and when a referral is warranted.

• You’re a key link in the interdisciplinary chain. Identifying possible esophageal involvement can help patients get to the right specialist sooner, reducing risks and improving outcomes.

• Your role extends beyond identification. While you won’t be treating achalasia or performing manometry, you will be the one helping patients stay safe with compensatory strategies, diet modifications, and swallow techniques until definitive treatment is in place.

• Patient education matters. As a clinician, you play a critical role in helping patients understand their diagnosis, reinforcing adherence, and building confidence in the plan of care.

By broadening your perspective to include the esophageal phase, you make your evaluations more complete, your referrals more accurate, and your patients’ care more effective.

Next steps in dysphagia care

Esophageal dysphagia is not just “GI territory.” For SLPs, it’s an essential part of the swallow chain that you can’t afford to overlook. Clinical interviewing, recognition of symptom patterns, and awareness of instrumental assessments all contribute to more accurate diagnoses and better patient outcomes.

The case of Parkinson disease and achalasia is only one example of how a comprehensive approach can reveal hidden contributors to swallowing difficulty. If you want to go deeper into the anatomy, physiology, assessment methods, and additional case studies, explore my Medbridge course series:

• Esophageal Dysphagia Part 1: Anatomy, Physiology, and Assessment

• Esophageal Dysphagia Part 2: Esophageal Disorders and Their Management

• Esophageal Dysphagia Part 3: Implementing an Esophageal Screen in the MBSS

• Esophageal Dysphagia Part 4: Belching and Rumination Disorders

• Esophageal Dysphagia Part 5: GERD Concepts for the SLP

References

1. Jones, B., Ravich, W. J., Donner, M. W., Kramer, S. S., & Hendrix, T. R. (1985). Pharyngoesophageal interrelationships: observations and working concepts. Gastrointestinal radiology, 10(3), 225–233. https://pubmed.ncbi.nlm.nih.gov/4029538/

2. Ioannou, A., & Torresan, F. (2024). Esophageal Achalasia in Parkinson's Disease: Diagnosis and Management of a Rare Case. Translational medicine @ UniSa, 26(1), 52–55. https://pmc.ncbi.nlm.nih.gov/articles/PMC11949495/

3. Levine, M. S., Rubesin, S. E., & Laufer, I. (2008). Barium esophagography: a study for all seasons. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 6(1), 11–25. https://pubmed.ncbi.nlm.nih.gov/18083069/

4. Carlson, D. A., & Pandolfino, J. E. (2013). High-resolution manometry and esophageal pressure topography: filling the gaps of convention manometry. Gastroenterology clinics of North America, 42(1), 1–15. https://pmc.ncbi.nlm.nih.gov/articles/PMC3790578/