Pediatric Dysphagia: An Otolaryngologic Perspective
Dysphagia is anatomically classified into oral, pharyngeal, and esophageal phases. We review evaluation and treatment focused on surgical management.
Pamela A. Mudd, MD, MBA, and Nancy M. Bauman, MD
Pediatric dysphagia, defined as difficulty in swallowing, is a complex, multifactorial condition necessitating a multidisciplinary, patient-centered approach to diagnosis and management. Over the years, the authors have developed and refined a comprehensive annual course on this subject, integrating expertise from speech-language pathology and pediatric gastroenterology. We are pleased to share key insights from this program.
At many institutions, including ours, pediatric dysphagia has become the most common referral to aerodigestive clinics. This condition significantly impacts both health and quality of life for pediatric patients and their families. From the otolaryngologist’s perspective, the evaluation often prioritizes identification of anatomical contributors to dysphagia, with particular attention to those amenable to surgical correction. This surgical lens distinguishes our unique role within the broader multidisciplinary team.
Pathophysiology and Developmental Considerations
Swallowing is a highly coordinated neuromuscular function involving over 30 muscles and cranial nerves V, VII, IX, X, and XII. The developmental trajectory begins in utero:
- Lip movement is observed by 10 weeks of gestation
- Nonnutritive sucking emerges at 27 weeks
- A coordinated suck-swallow-breathe (SSB) pattern—critical for safe oral feeding—develops around 34 weeks
This SSB pattern allows infants to feed while maintaining adequate ventilation and airway protection. Preterm infants who are less than 34 weeks of gestation may not possess the neurodevelopmental skills necessary to feed orally. Infants with anatomic concerns like laryngomalacia, vocal fold immobility, laryngeal cysts, or those with neuromuscular delay often struggle with this coordination, leading to aspiration, desaturations, and/or feeding intolerance. Infants with cardiopulmonary disease may not be able to tolerate the brief but repeated periods of apnea characteristic of the SSB pattern.
Swallowing continues to evolve postnatally. Term infants swallow ~500 mL of amniotic fluid daily, influenced by sensory input including taste. Feeding skills progress from suckling to mature chewing with lateral and rotary jaw movements typically developing during the third year of life, explaining the recommendation to avoid peanuts, hard carrots, and similar choking-risk foods in young toddlers.
Classification and Clinical Features
Dysphagia is a subset of the broader category of “feeding disorders,” which may also include issues such as oral aversion that impact nutritional intake without an anatomical or physiological basis. Symptoms of dysphagia may be obvious (choking, coughing, refusing food) or subtle (apnea, bradycardia, oxygen desaturation, recurrent respiratory infections). The clinical presentation depends on both the phase of dysphagia and the patient’s age and comorbidities.
Dysphagia is anatomically classified into oral, pharyngeal, and esophageal phases. Otolaryngologists most frequently evaluate and manage pharyngeal dysphagia, typically presenting as penetration or aspiration events observed on instrumental swallow assessment including videofluoroscopic swallow study (VFSS) or functional endoscopic evaluation of swallowing (FEES). However, recognizing oral dysphagia from causes such as ankyloglossia, or esophageal dysphagia from cricopharyngeal achalasia, requires a broad understanding of each phase.
Evaluation Strategies
A comprehensive evaluation begins with:
- Detailed history (feeding behaviors, respiratory symptoms, growth, development, perinatal events)
- Physical exam (craniofacial features, cranial nerve function, oral reflexes, secretion control)
- Flexible nasopharyngolaryngoscopy (airway dynamics, structural anomalies)
Further diagnostics depending on presenting symptoms and findings may include:
- Bedside swallow evaluation/clinical feeding evaluation
- Videofluoroscopic swallow study
- Functional endoscopic evaluation of swallowing
- Direct laryngoscopy and bronchoscopy (DLB)
- Esophagoscopy, esophageal manometry
- Ancillary tests, such as neuroimaging, genetic panels, metabolic, or psychological assessments
Collaborative Roles in Management
Speech-Language Pathology (SLP)
- Performs bedside assessments and determines whether dysphagia or oral aversion is present
- Guides selection of instrumental evaluations (e.g., VFSS vs. FEES)
- Initiates and monitors feeding therapies, which may include:
- Thickening of feeds
- Pacing and positioning strategies
- Food chaining (gradual introduction of new foods based on accepted textures and flavors)
- Oral motor exercises
- Behavioral desensitization
Gastroenterology (GI)
- Assesses nutritional status and diagnoses of GI conditions including pathologic reflux (GERD), cow’s milk protein allergy, eosinophilic esophagitis, oral candidiasis, and motility disorders
- Emphasis of suspected GERD management has shifted away from empiric acid suppression toward formula modification to address reflux triggers
- Evaluates need for endoscopy to assess esophageal mucosa and to rule out structural abnormalities
Pulmonology
- Assesses the impact of dysphagia on respiratory function and the potential for aspiration-related short- and long-term sequelae
- Manages respiratory infections by optimizing airway clearance, prescribing appropriate antimicrobial, performing other systemic and inhaled therapies, and maneuvering to aid airway clearance, such as postural drainage and chest physiotherapy
Surgically Amenable Otolaryngologic Conditions
Surgically correctable etiologies of pediatric dysphagia are relatively uncommon when compared to neuromuscular causes; however, identifying candidates for surgical intervention remains critical for timely management and favorable outcomes. Flexible nasopharyngolaryngoscopy, often complemented by direct laryngoscopy and bronchoscopy, serves as the primary diagnostic modality for pediatric otolaryngologists in evaluating structural causes of dysphagia. The differential diagnosis for structural etiologies is broad and includes, but is not limited to:
- Choanal atresia or anomalies causing nasal obstruction
- Cleft lip/cleft palate
- Ankyloglossia
- Laryngomalacia
- Laryngeal cleft or low interarytenoid height
- Vocal fold immobility (VFI)
- Cricopharyngeal achalasia
- Post-cricoid vascular cushion
- Vascular anomalies (double aortic arch, pulmonary sling, retroesophageal subclavian artery)
- Persistent or undiagnosed tracheoesophageal fistula
- Tracheoesophageal pouch
The following are otolaryngologic surgical considerations for pharyngeal and esophageal dysphagia.
Laryngeal Cleft or Interarytenoid Incompetence: Type 2-4 laryngeal clefts require layered closure via endoscopic or open repair. In suspected Type 1 laryngeal cleft, or low interarytenoid height, injection with carboxymethylcellulose can reduce aspiration. Although not universally adopted, this technique is low risk when performed during DLB and may serve both diagnostic and therapeutic purposes.
Vocal Fold Immobility: Post-cardiac surgery VFI remains a frequent cause of pediatric dysphagia. Neurologic or neurosurgical cases of VFI are also common. The goals of early surgical management with injection medialization extend beyond simply improving the voice. In this context, surgery may aim to support improved airway coordination with swallow, improve effective airway clearance and cough, and enhance glottic closure for airway protection and appropriate subglottic pressure that is critical to swallow and pharyngeal squeeze. Long-term options include medialization thyroplasty or reinnervation.
Laryngomalacia: When dysphagia is the predominant symptom, supraglottoplasty may improve coordination of the SSB pattern and reduce aspiration risk. However, worsening aspiration postoperatively can occasionally occur, particularly in developmentally delayed infants, necessitating careful pre-operative selection of patients.
Cricopharyngeal Achalasia: This is rare in neonates but may present as pooling of secretions or oral intake above the upper esophageal sphincter. Initial treatment can include botulinum toxin injection; myotomy offers a more definitive option for persistent cases.
Post-Cricoid Vascular Cushion: This is an enlarged venous plexus that can mimic hemangioma, often more prominent during crying. Flexible laryngoscopy may miss this finding unless crying is present. Symptomatic cases can benefit from coblation or laser reduction.
Vascular Rings and Tracheoesophageal Fistulae: MRI complements operative findings to delineate aortic arch anomalies. H-type fistulae require high suspicion and meticulous inspection of the posterior tracheal wall. A high index of suspicion is also required for diagnosis of a persistent TEF or a large tracheoesophageal pouch following TEF repair.
Key Principles for Otolaryngologists
Please keep in mind these key principles, particularly for otolaryngologists:
- Diagnostic Precision: Careful endoscopic assessment is critical
- Targeted Surgical Intervention: Surgical management is tailored to the patient's pathology with consideration of age, medical comorbidities, feeding trajectory, and family preferences
- Multidisciplinary Collaboration: Integration of care with SLPs, gastroenterologists, and pulmonologists is essential
Conclusions
Pediatric dysphagia is a growing and complex challenge within otolaryngology. Our role in evaluating and managing surgically amenable causes is critical but best exercised within a multidisciplinary framework. Understanding the developmental underpinnings of swallowing, coordinating with allied specialists, and selecting targeted interventions remain essential to improving outcomes in this vulnerable population.
