The main aims are to exclude a potentially fatal pathology such as cancer, and

to identify a potentially treatable cause. The choice of test(s) depends largely upon the perceived underlying cause, as the sensitivity and specificity of each test differs depending on the underlying condition, in large part because of the inherent capability of the technique. Given the differences in the causes as well as the anatomical structures responsible for oropharyngeal and esophageal dysphagia, the approaches for their investigation are different. Available diagnostic tests include standard barium swallow, modified barium swallow, nasoendoscopy, and pharyngeal manometry. Modified barium swallow is carried out by both a radiologist and speech pathologist. It offers real-time assessment and recording of oropharyngeal coordination and the presence and extent of aspiration, and allows instant feedback on the effect find more of swallowing maneuvers and posture. Nasoendoscopy, also known as fiber optic endoscopic examination of swallowing, not only allows direct visualization of lingual, pharyngeal, and epiglottic movements during swallowing but also assesses the presence of

any pharyngeal retention of liquids or solids after swallowing. Pharyngeal manometry is particularly useful in detecting failure of upper esophageal sphincter relaxation, the presence of which indicates Everolimus cost potential therapeutic benefit with cricopharyngeal myotomy or dilatation, although evidence for this is largely anecdotal. Mechanical causes, such as an obstructing mass lesion or stricture, are predominantly identified during gastroscopy, while motility disorders such as achalasia and spasm are diagnosed

by manometry. However, a video barium swallow remains a useful investigation and, in some situations, outperforms gastroscopy. Assessment of esophageal motility has advanced substantially over recent Amoxicillin decades, having progressed from single-channel manometry to the modern day 36-channel high-resolution manometry with topography,5 impedance monitoring,6,7 planimetry,8,9 and intraluminal ultrasound.10 However, each of these techniques is only designed to measure one out of three important aspects of esophageal motor function assessment namely, muscular contractile activity, intraluminal pressure, and bolus transit. To overcome this, a combined approach incorporating more than one technique is being increasing adopted. The barium swallow remains a widely available and relatively inexpensive first-line investigation for dysphagia. It remains attractive in those who are either poorly tolerant of, or unfit to undergo, other procedures, such as gastroscopy. Fluoroscopy offers real-time and continuous viewing of the bolus during transit from the oropharynx into the stomach, and transit of both liquid and solid boluses should be evaluated.