Odynophagia: the symptom you should not ignore

Odynophagia is a medical term that refers to pain experienced when swallowing food, liquids, or even saliva. Although it may seem like a trivial symptom, in many cases it can indicate significant underlying conditions that require clinical evaluation.

What is odynophagia?

Odynophagia is defined as pain during swallowing. Unlike dysphagia, which involves difficulty swallowing, odynophagia is specifically characterized by a painful sensation that may be localized in the throat, chest, or even the retrosternal area. This symptom may be associated with multiple disorders, ranging from mild infections to malignant diseases of the upper digestive tract.

Difference between odynophagia and dysphagia

It is essential to distinguish odynophagia from dysphagia. While dysphagia refers to the sensation that food does not pass properly or becomes stuck, odynophagia involves pain during the swallowing process, without necessarily impairing the passage of the food bolus. Both may coexist, but their underlying causes and treatment can be very different.

Common causes of odynophagia

There are various causes of odynophagia, some benign and transient, and others more serious that require immediate medical attention. The main ones are listed below:

1. Infections

• Viral or bacterial pharyngitis: One of the most common causes. Infections caused by streptococcus, adenovirus, or Epstein–Barr virus can lead to inflammation and pain during swallowing.

• Tonsillitis: Inflammation of the tonsils can cause severe odynophagia, especially in the presence of abscesses.

• Oral candidiasis: In immunocompromised patients or those with prolonged use of antibiotics or inhaled corticosteroids, infection with Candida albicans can affect the oropharynx and cause pain during swallowing.

• HIV infection: In advanced stages, it may cause painful oral ulcers and infectious esophagitis

2. Gastroesophageal reflux and esophagitis

Gastric acid content can reflux into the esophagus, leading to esophagitis and, consequently, odynophagia. This type of pain typically worsens when lying down or after large meals.

3. Esophageal ulcers

They may result from chronic acid reflux, infections such as cytomegalovirus or herpes esophagitis in immunocompromised patients, or from irritating medications such as NSAIDs, bisphosphonates, and tetracyclines.

4. Trauma or mechanical irritation

• Consumption of very hot foods or foods with sharp edges (such as hard crusts)

• Accidental ingestion of foreign bodies (fish bones, bone fragments)

• Endotracheal intubation or invasive medical procedures

5. Neoplasms

Esophageal, oropharyngeal, or laryngeal cancer may present with progressive odynophagia, often associated with weight loss, dysphonia, and cervical lymphadenopathy.

6. Oncological treatments

Radiotherapy directed to the neck or chest and certain types of chemotherapy can cause inflammation of the esophageal and pharyngeal mucosa.

7. Other causes

• Food allergies with mucosal inflammation

• Autoimmune diseases such as Behçet’s disease or Crohn’s disease with esophageal involvement

• Esophageal spasms or motility disorders of the esophagus

Associated symptoms

Odynophagia may be accompanied by other symptoms that help guide the diagnosis:

• Fever (infection)

• Dysphagia (structural or neuromuscular disorder)

• Cough, hoarseness (laryngeal or tracheal involvement)

• Acid reflux, heartburn (gastroesophageal reflux disease)

• Weight loss, fatigue (in chronic or malignant conditions)

• Halitosis (tonsillitis, chronic infections)

Diagnosis

The diagnostic approach should be comprehensive and tailored to the severity of the condition:

Clinical history

A history of infections, recent treatments, habits such as smoking or alcohol use, exposure to irritants, and comorbidities is assessed.

Physical examination

Oropharyngeal inspection, cervical palpation, and assessment of speech, breathing, and swallowing.

Complementary tests

• Pharyngeal swab or culture for the diagnosis of bacterial infections.

• Upper gastrointestinal endoscopy to visualize the esophagus and detect ulcers, neoplasms, or deep infections.

• Laryngoscopy if laryngeal involvement is suspected.

• Biopsies in cases of suspicious lesions.

• Blood tests, serological studies, or specific tests in immunocompromised patients.

Treatment

Treatment of odynophagia depends entirely on the underlying cause:

1. Infections

• Antibiotics for streptococcal pharyngitis or bacterial tonsillitis.

• Antiviral therapy in severe infections such as herpes or cytomegalovirus in immunocompromised patients.

• Antifungal therapy for oral candidiasis (e.g., nystatin or fluconazole).

2. Reflux and esophagitis

• Proton pump inhibitors (omeprazole, pantoprazole) and dietary measures.

• Avoid irritant foods, alcohol, tobacco, and elevate the head of the bed.

3. Mechanical or chemical injuries

• Soft diet and analgesics to allow healing.

• Discontinuation of aggressive medications when possible.

4. Neoplasms

• Urgent referral to oncology

• Treatments such as surgery, chemotherapy, or radiotherapy depending on the stage

5. Symptomatic pain

• Analgesics (paracetamol, NSAIDs if not contraindicated)

• In severe cases, viscous lidocaine or topical anesthetics to facilitate swallowing

Complications

Failure to adequately treat odynophagia may lead to serious consequences:

• Dehydration due to avoidance of fluid intake.

• Malnutrition, especially in patients with chronic odynophagia.

• Pharyngeal abscesses in advanced infections.

• Esophageal perforation in cases of severe ulcers or foreign bodies.

• Systemic spread of infections in immunocompromised patients.

Prevention

Some measures can help prevent episodes of odynophagia:

• Avoid self-medication with antibiotics.

• Maintain good oral hygiene.

• Prompt treatment of respiratory infections.

• Avoid smoking and excessive alcohol consumption.

• Control acid reflux through diet and medication.

• Avoid consuming foods at extreme temperatures or with very rough textures.

Conclusion

Odynophagia is a symptom that warrants medical attention when it is persistent, severe, or associated with other concerning signs. Identifying the exact cause is essential to implement appropriate treatment and prevent complications. Although it is often associated with mild and self-limiting infections, it should not be underestimated, especially in the presence of immunosuppression, chronic exposure to irritants, or systemic symptoms. A multidisciplinary approach involving primary care physicians, otolaryngologists, and gastroenterologists may be key to resolving the condition effectively and safely.

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