I. Under what circumstances should I be alerted to a possible swallowing disorder? When the following danger signs appear, please be alert to the possible existence of swallowing disorder and need further examination. 1.Inability to swallow food or medication; 2.Coughing and choking when swallowing, especially when drinking water; 3.Feeling that food stops in the esophagus or chest after swallowing; 4.Food residue in the mouth after eating or feeling that food is returning to the mouth; 5.Frequent heartburn or bitterness in the mouth; 6.Changing of voice; feeling a sense of wetness or gurgling sound in the voice when communicating; 7.Frequent throat-clearing movements, especially when eating; 8.Recurrent unexplained occurrences of dysphagia. 8. Recurrent unexplained pneumonia; 9. Other related factors: persistent weight loss and malnutrition; 10. History of related diseases: stroke, traumatic brain injury, neuromuscular disease, diabetes, thyroid disease, dementia, recent history of botulinum toxin injection. It is important to be alert to the fact that some patients are not self-aware of swallowing disorders, and some patients do not have obvious choking symptoms (silent aspiration, so the absence of complaints and choking symptoms does not mean that there is no swallowing problem. What physical examination is required when swallowing disorder is suspected? 1.General physical examination, including nutritional status, weight, vision, etc. 2. Arousal level examination and mental intelligence status examination: to determine the patient’s risk of swallowing and ability to cooperate with treatment. 3.Cranial nerve function examination of the head and neck, especially V, VII, IX, X and XII pairs of cranial nerve examination. 4.Examination of the mouth, lips, teeth, soft palate and pharynx, as described in the rehabilitation assessment below. 5. Palpation of the neck for masses, auscultation for local murmurs and examination of the thyroid gland for abnormalities. 6. Auscultation of the lungs for dry and wet snail stringing L escape 7. Neurological signs also need to include examination of muscle strength, reflexes, motor coordination and postural position. Third, the diagnostic examination of swallowing disorder diagnostic examination needs to follow the following two major types of questions. 1.Is there a swallowing disorder? 2. In which period of time does the swallowing disorder occur? Obvious dysphagia and choking can be diagnosed by history and physical examination. However, some patients have silent aspiration. Therefore, the following tests may be needed to further clarify the location and severity of the swallowing disorder. (1) Swallowing imaging: The most common diagnosis of pharyngeal dysphagia is barium meal imaging. The effectiveness of VFSS can also be evaluated when an anti-misopharyngeal swallowing strategy is used. (2) Fiberoptic endoscopy: FEES is a more practical test when the patient cannot be transported to radiology for swallowing angiography due to medical limitations. This method can be used to detect abnormalities in any area, including the nasopharynx, oropharynx and laryngopharynx. (3) Ultrasonography: It is used to understand the soft tissue motility during the oral preparatory phase, oral transit phase and pharyngeal phase. Ultrasonography is particularly useful for coordinated tongue movement disorders in children with swallowing disorders, and when used in combination with fiberoptic bronchoscopy can compensate for the inability of fiberoptic bronchoscopy to detect submural or extra-mural injuries. (4) Transnasal esophagoscopy: suitable for esophageal examination (e.g., tumors and diverticula). (5) Nuclear imaging: The patient is usually asked to swallow a radionuclide 99mTc-labeled gel developer. The scan covers the oral area, neck and chest. The advantage of this test is its ability to quantify the rate and extent of misaspiration and also to detect salivary misaspiration without choking. (6) Simultaneous barium meal pressure gradient imaging: A manometer is used to detect pressure gradient changes in the pharynx and pharyngoesophageal junction at the same time as the imaging. (7) Electromyography: mainly used for the functional examination of single muscle. (8) Neck auscultation: When no other examination equipment is available, the easiest and most practical method is to place a stethoscope on the neck to listen to the typical swallowing sounds. 2.What is the primary disease of swallowing disorder? The following tests may be helpful for the primary disease of swallowing disorder: (1) serological tests: vitamin B12, thyrotropin, creatine kinase and other blood biochemical indicators; (2) CT or MRI of the head and neck; (3) chest X-ray and pulmonary function tests; (4) brainstem auditory evoked potentials and visual evoked potentials; (5) some neurogenic swallowing disorders can only be diagnosed by neurolocalization diagnostics. (5) Some neurogenic swallowing disorders can only be diagnosed by neurolocalization diagnostic examination. Differential diagnosis of swallowing disorders Swallowing disorders are not a disease diagnosis, but a general term for a series of symptom descriptions, or a functional diagnosis. Therefore, when a diagnosis of swallowing disorder is reached in clinical practice, the following differential must be made. 1.Stage differentiation According to the physiological stage of ingestion and swallowing to identify in which specific period and part of the swallowing disorder occurs. In clinical practice, the first distinction is made between ingestion disorder, oropharyngeal swallowing disorder and esophageal swallowing disorder. This distinction can often be accomplished by taking a detailed history. The following questions must be included in the history taking: (1) Where did the swallowing difficulty occur? (2) What is the nature of the food that triggered the swallowing disorder? (3) Is the swallowing disorder progressive or intermittent? (4) How long do the symptoms last? Patients with oropharyngeal dysphagia complain of discomfort mostly in the oropharynx and neck, and often present with inability to swallow, regurgitation of food into the nasal cavity, coughing or breath-holding during swallowing (but note that some aspiration is asymptomatic), pronounced nasal sounds or poor diction during conversation, bad taste in the mouth, and cranial nerve-related symptoms (e.g., neurogenic oropharyngeal dysphagia caused by multiple sclerosis may be accompanied by diplopia). If it is an oropharyngeal dysphagia, then further identification of oral preparatory phase, oral transit phase, and pharyngeal phase dysphagia is required. The complaints of esophageal dysphagia for discomfort are mostly located in the lower neck and chest, and a few patients have heartburn and chest pain, even misdiagnosed as angina pectoris. If a patient has dysphagia with solid food, it suggests the presence of structural abnormalities of the esophagus, and gastrointestinal endoscopy is feasible. If the patient complains of progressive worsening of swallowing disorder, preference for soup and porridge food, and accompanied by rapid weight loss, it is necessary to be alert for gastrointestinal tumor. At this time, the cervical and supraclavicular lymph nodes must be explored by palpation, and other laboratory and instrumental tests must be performed. If the patient has difficulty swallowing both liquid and solid foods, intermittent episodes of symptoms with chest pain suggest the presence of esophageal dysfunction, and swallowing angiography is feasible. 2. Etiology identification (1) Central nervous system diseases: stroke; traumatic brain injury; Parkinson’s disease; Alzheimer’s disease; amyotrophic lateral sclerosis; multiple sclerosis; brain tumor; Guillain-Barré syndrome; Huntington’s chorea central nervous system infection; post-polio syndrome/myasthenia gravis. (2) Neuromuscular junction disorders: myasthenia gravis. (3) Myopathy: myasthenia gravis; spinal muscular atrophy; poliomyelitis; polymyositis; dermatomyositis. (4) Peripheral neuropathy: for example, sensory neuropathy involving the laryngeal nerve. (5) Endocrine system disorders: myopathy caused by cortisolism, hyperthyroidism and hypothyroidism; vitamin B12 deficiency leading to cortical medullary tract dysfunction, resulting in pseudobulbar palsy. (6) Medically induced dysphagia: Drugs: antipsychotics, central system depressants, corticosteroids, lipid-lowering drugs, colchicine, aminoglycoside antibiotics, anticholinergic drugs. Pay particular attention to the significant association of H2 receptor antagonists with swallowing disorders. Surgery: palatopharyngoplasty for obstructive sleep apnea may lead to soft palate dysfunction, and carotid endarterectomy, cervical fusion, or thyroid surgery may damage the pharyngeal plexus. (7) Other serious diseases: tumors of the digestive tract, tumors of the ear, nose and throat, and mediastinal areas. CREST syndrome due to scleroderma (subcutaneous calcium deposits, Raynaud’s phenomenon, esophageal hypotonia, extremity sclerosis, capillary dilation). (8) Psychogenic swallowing disorder: a diagnosis of exclusion, characterized by loss of use of the mouth and lips, but normal speech communication ability and function of the cranial nerves innervating the pharynx. It is usually accompanied by depression, anxiety, gastrointestinal discomfort, hypochondriasis, or abnormal eating behavior. Swallowed foreign bodies may be found in the stomach. 3, special identification: true and pseudo medullary palsy Central nervous system disorders caused by swallowing disorders, pay particular attention to identify the medullary palsy (also known as ball palsy) in the two different types: true medullary palsy and pseudo medullary palsy. In the absence of treatment, both are equally dangerous. However, pseudomyelitis is more effective than true medulla oblongata for rehabilitation.