Abstract
Objective: To present a case of Amyotrophic Lateral Sclerosis (ALS) with an unusual initial presentation of dysphagia.
 Methods: 
 Design: Case Report
 Setting: Private tertiary university hospital
 Patient: One
 Results: A 78-year-old female with two years’ progressive dysphagia thrice refused biopsy of a right oropharyngeal bulge recommended by three differenet otorhinolaryngologists. Slurring developed, but normal cranial CT scans cleared her of a cerebrovascular event. Subsequent marked weight loss, dysarthria and lower extremity weakness led to tests including an electromyogram and nerve conduction velocity study (EMG-NCV) consistent with amyotrophic lateral sclerosis (ALS).
 Conclusion: Awareness of neurologic disorders that cause dysphagia may prevent unnecessary diagnostic interventions. Algorithms for evaluation and management of dysphagia may also reduce misdiagnosis and consequent mismanagement. ALS may be considered whenever symptoms of dysphagia present with subsequent development of other motor neurologic signs of denervation such as fasciculation, weakness and atrophy. Otorhinolaryngologists play a vital role in the ALS team in light of the need for thorough swallowing evaluation and airway support.
 Key words: dysphagia, Amyotrophic Lateral Sclerosis (ALS), bulbar-onset ALS, oropharyngeal mass
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