abnormality of the trachea, esophagus, or larynx Congenital vascular lesions causing extrinsic compression of the esophagus may remain silent until the introduction of solid food, or may rarely manifest as dysphagia later in adulthood Gastroesophageal reflux in infants may manifest as vomiting shortly after feeding or with a history of nighttime cough or emesis Intrinsic lesions, from inflammation, tumor, or foreign body, may create problems with solid food but cause no difficulty with liquids Infants with previously unrecognized neuromuscular disorders commonly present initially with dysphagia, particularly for liquids, drooling, prolonged feeding time, weak suckle, or nasal reflux of swallowed material A history of fever may indicate aspiration pneumonia or other infectious or inflammatory causes of dysphagia Determining whether symptoms are progressive or intermittent/nonprogressive can also be helpful The child with dysphagia should undergo a thorough general physical examination, initially focusing on the patient’s cardiopulmonary status Evidence of respiratory distress or cardiovascular compromise should be treated promptly in the appropriate manner, as outlined elsewhere in this text (see Chapters Airway and Cardiopulmonary Resuscitation ) Assurance of a secure and stable airway should precede attempts to examine the oropharynx or to remove a foreign body (see Chapter 32 Foreign Body: Ingestion and Aspiration ) In the stable dysphagic patient, evaluation of head size and shape, facial structure, mandibular development, tongue disproportion, and ear configuration may provide evidence of an underlying congenital abnormality, such as Pierre Robin, Treacher Collins, Crouzon, and Goldenhar syndromes Evaluation of nasal airway patency in the infant can be determined by gently passing an 8F catheter through the nares into the stomach If the catheter fails to pass easily, choanal stenosis, atresia, or esophageal obstruction must be considered Inspection of the oral cavity, pharynx, and neck may reveal a cyst, mass, localized infection, or inflammatory cause for dysphagia Cervical auscultation over the thyroid cartilage during feeding may note evidence of aspiration if upper airway breath sounds are abnormal or if the timing of breathing and swallowing is uncoordinated The pulmonary examination may also detect signs of aspiration or respiratory compromise, including elevated respiratory rate, increased respiratory effort, stridor, stertor, rales, rhonchi, wheezing, or change in voice quality Neurologic examination may reveal an altered level of arousal from an underlying brain injury or depressed sensorium from drugs or infection that may limit effective swallowing Examination of the cranial nerves, particularly V, VII, IX, X, and XII, may reveal abnormalities from traumatic or surgical injury, tumor, or congenital disorder Evaluation of muscle tone, strength, and reflexes in