an acute onset of dysphagia generally requires a more urgent approach Witnessed or suspected foreign bodies, either ingested or aspirated, should be investigated with plain radiographs (or contrast studies if a radiolucent object is considered) and, emergently removed as indicated (see Chapter 32 Foreign Body: Ingestion and Aspiration ) A history of neck trauma or caustic ingestion should lead to concern for aerodigestive tract abnormalities These patients may present dramatically with neck pain, drooling, and evidence of facial or other trauma, but they may also have a subacute presentation (see Chapters 102 Toxicologic Emergencies , 106 ENT Trauma , and 112 Neck Trauma ) Presence of fever or signs of systemic illness may result from potentially life-threatening infectious or inflammatory conditions ( Table 56.3 ) Less severe problems (gingivostomatitis or thrush) may present with mouth lesions and can be managed on an outpatient basis after careful assessment of hydration status Severe problems, including Stevens–Johnson syndrome, herpetic esophagitis, and diphtheria, may be discovered on examination and likely will require inpatient management Patients with a nonacute history of swallowing difficulty can be evaluated and managed as shown in Figure 56.2 The initial emphasis with these patients lies more in determination of nutritional status and development issues than in acute emergency department intervention, although prolonged feeding difficulty can develop into a life-threatening problem Evaluation of these patients often involves a multidisciplinary approach The child with obvious anatomic abnormalities, neurologic impairment, specific syndromes, or a tracheostomy may need referral to appropriate subspecialists after initial evaluation The child without obvious anatomic or neurologic abnormality who has weight loss or failure to thrive may be evaluated as an outpatient Radiographic evaluation of the stable dysphagic patient usually begins with an examination of the airway and soft tissues of the neck, looking for evidence of a foreign body, mass, airway impingement, or other abnormality A chest radiograph may suggest aspiration pneumonia, congenital heart disease, or mediastinal abnormality or, as in the patient with achalasia, demonstrate fluid levels within an enlarged esophagus Helical computed tomography scan, echocardiography, or angiography may further identify problems suspected from initial studies A videofluoroscopic swallowing study (VFSS or modified barium swallow [BS]) is currently the gold standard for evaluating pre-esophageal disorders This dynamic study may reveal evidence of aspiration, nasopharyngeal reflux, motility disorders, obstructions, masses, cricopharyngeal dysfunction, fistulas, inflammatory processes, or other causes of dysphagia VFSS differs from the