Domenico A Restivo ¹ Angelo Quartarone ² Antongiulio Bruschetta ³ Angelo Alito ⁴ Demetrio Milardi ⁴ Rosario Marchese-Ragona ⁵ Ennio Iezzi ⁶ Sheila Peter ⁶ Diego Centonze ^6,7 Mario Stampanoni Bassi ^8*

• ¹ Department of Clinical and Experimental Medicine, Physical Medicine and Rehabilitation Unit, University of Messina, Messina, Italy
• ² IRCCS “Fondazione Bonino-Pulejo”, Messina, Italy
• ³ Orthopaedic Institute of Southern Italy 'Franco Scalabrino'., Messina, Italy
• ⁴ Brain Mapping Lab, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
• ⁵ ENT Department, University of Padua, Padova, Italy
• ⁶ Unit of Neurology, IRCCS Neuromed, Pozzilli (IS), Italy
• ⁷ Department of Systems Medicine, Faculty of Medicine and Surgery, University of Rome Tor Vergata, Rome, Lazio, Italy
• ⁸ Mediterranean Neurological Institute Neuromed (IRCCS), Pozzilli, Italy

Dysphagia is a frequent and life-threatening complication of multiple sclerosis (MS). Swallowing disturbances may be present at all stages of MS, although their prevalence increases with age, with disease duration, and in progressive phenotypes. The pathophysiology of dysphagia in MS is likely due to a combination of factors, including the involvement of corticobulbar tracts, the cerebellum, and the brainstem. Accurate diagnosis and early management of swallowing disorders improve quality of life and may delay complications or invasive therapeutic interventions.Here we provide an overview of the pathophysiology, the assessment, and the management of MS dysphagia, also examining the possible role of novel therapeutic strategies. Although studies using imaging and neurophysiological techniques have contributed to better characterize swallowing alterations in MS, the treatment of dysphagia is still challenging.Rehabilitation represents the main therapeutic approach for swallowing disorders. Recently, some innovative neurophysiological approaches, such as pharyngeal electrical stimulation (PES), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS), have been proposed as a supplement to swallowing therapy in different neurological conditions. However, only few studies have explored the role of neuromodulation for MS dysphagia.