Evaluation of dysphagia

Foreign body

Acute dysphagia can be due to foreign bodies and food impaction in the pharynx or esophagus. Associated symptoms include odynophagia, foreign body sensation, and excessive secretions.

Foods can also become lodged at the level of the upper esophageal sphincter, which may lead to airway obstruction and death from asphyxiation. This may respond to hard back slaps, chest thrusts for infants, or abdominal thrusts (Heimlich maneuver) for children and adults.[45]American Red Cross. Conscious choking. 2007 [internet publication]. http://www.redcross.org/flash/brr/English-html/conscious-choking.asp [46]Resuscitation Council UK. Paediatric basic life support guidelines. May 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-basic-life-support-guidelines [47]Perkins GD, Graesner JT, Semeraro F, et al. European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation. 2021 Apr;161:1-60. https://www.doi.org/10.1016/j.resuscitation.2021.02.003 http://www.ncbi.nlm.nih.gov/pubmed/33773824?tool=bestpractice.com

Patients should be stabilized with appropriate management of airway and circulation and take nothing by mouth. The next step in management of a food impaction is to determine the exact location of the impaction, which can be done by plain radiographs, flexible fiberoptic nasopharyngoscopy/laryngoscopy, or computed tomography (CT) scan. Esophagogastroduodenoscopy (EGD) plays an essential role in terms of showing the location, type of object, and configuration and providing a means of therapy.[48]ASGE Standards of Practice Committee; Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011 Jun;73(6):1085-91. http://www.ncbi.nlm.nih.gov/pubmed/21628009?tool=bestpractice.com

Caustic injury

Caustic injury can cause acute dysphagia, odynophagia, tongue edema, stridor, airway obstruction, aspiration, or perforation. It can also lead to cyanosis, hypoxia, fever, tachycardia, and shock.

Patients should be stabilized with appropriate management of airway and circulation and take nothing by mouth. Identification of the specific agent ingested may help further management. It is diagnosed with fiberoptic laryngoscopy. EGD is valuable but carries the risk of perforation. To rule out perforation due to caustic injury, x-ray with Gastrografin is safe, but barium should be avoided, as it can cause mediastinitis if a perforation exists. Chest radiograph can reveal perforation.[49]Cello JP, Fogel RP, Boland CR. Liquid caustic ingestion spectrum of injury. Arch Intern Med. 1980 Apr;140(4):501-4. http://www.ncbi.nlm.nih.gov/pubmed/7362380?tool=bestpractice.com [50]Gaudreault P, Parent M, McGuigan MA, et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983 May;71(5):767-70. http://www.ncbi.nlm.nih.gov/pubmed/6835760?tool=bestpractice.com

Stroke

Some 40% to 70% of people with stroke experience dysphagia.[2]World Gastroenterology Organisation. WGO practice guideline - dysphagia. Sep 2014 [internet publication]. http://www.worldgastroenterology.org/guidelines/global-guidelines/dysphagia The consequence of dysphagia in this population can be aspiration of solid and/or liquid food into the respiratory tract, which can lead to life-threatening pneumonia.[51]Simon M, Reuther S, Schreier MM, et al. Risk for dysphagia screening tools - a review of the international literature. Pflege. 2009 Jun;22(3):193-206. http://www.ncbi.nlm.nih.gov/pubmed/19496032?tool=bestpractice.com [52]Dziewas R, Michou E, Trapl-Grundschober M, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. European Stroke Journal. Oct 2021 [Epub ahead of print]. https://journals.sagepub.com/doi/10.1177/23969873211039721 The goal of the initial evaluation is to ensure medical stability, perform an abbreviated neurologic exam, and rapidly transport the patient to the CT or magnetic resonance imaging scanner so as to identify ischemia versus hemorrhage. Because of time constraints, certain portions of the history and physical exam may be deferred until after both scanning and the decision to perform thrombolysis (in ischemic stroke). Patients should take nothing by mouth until a standardized swallowing assessment has been performed.