A variety of structural and functional disorders can disrupt the oropharyngeal phase of deglutition and result in oropharyngeal or "transfer"-type dysphagia (Table 4). In the assessment of these patients it is important to exclude disorders for which specific treatment is available.

The most important investigation is a carefully performed video fluoroscopic study of the swallowing mechanism. In addition to the usual barium studies, it is helpful to observe deglutition when the patient swallows barium-soaked cookies or bread. Not only will this examination identify and characterize disorders of oropharyngeal coordination, it will also help exclude structural lesions. If an inflammatory, neoplastic or other structural lesion is suspected, direct or indirect laryngoscopy is indicated. At present, conventional manometric studies of the pharynx and UES add little to what can be learned from radiologic studies. This is partly because of limitations in recording methods, but also because complex motor events occurring during deglutition (e.g., closure of the nasopharynx, elevation and closure of the larynx - see Section 3, "Physiology") are not amenable to manometric study.

Ideally, treatment of oropharyngeal motor disorders should be directed at the underlying disease. Frequently this is not possible, and nonspecific treatment must be instituted. In some cases reassurance and education are all that is required. Many patients will be able to control their symptoms simply by eating slowly and carefully in a relaxed atmosphere. In patients in whom aspiration develops because of inadequate clearing of the hypopharynx after the initial swallow, it is beneficial to have the patient immediately follow a "bolus" swallow with a second, "dry" swallow. Correcting denture problems and avoiding foods of certain consistency may also help. Most speech pathologists have special expertise as swallowing therapists and can be extremely helpful in the management of these patients.

For patients in whom these simple measures are not helpful and whose symptoms are such that respiratory and nutritional complications are developing, cricopharyngeal myotomy is often performed. This helps patients with true cricopharyngeal achalasia or Zenker's diverticulum (Section 13). Unfortunately, the response to myotomy is inconsistent in most other patients with oropharyngeal dysphagia, because inadequate opening of the UES is rarely due to dysfunction of the cricopharyngeal muscle alone. More often there is associated weakness of the suprahyoid muscles, which actually open the sphincter, and/or associated problems with pharyngeal peristalsis. Cricopharyngeal myotomy does little to improve such altered physiology. Once cricopharyngeal myotomy has been performed, the patient has lost an important defense mechanism against the aspiration of refluxed material. The patient should therefore be instructed to elevate the head of his or her bed on blocks in order to minimize this risk. For this same reason patients with gross GERD should not undergo cricopharyngeal myotomy unless the reflux can be controlled.

When all other measures fail and nutritional and respiratory complications develop, percutaneous endoscopic gastrostomy should be performed. If the problem is so severe that the patient cannot handle salivary secretions, it is sometimes necessary to also perform laryngeal exclusion and tracheotomy.