Differential Diagnosis
The patient's symptoms of episodic swallowing difficulties, tachycardia, numbness, tingling, and dysphagia, along with the results of various diagnostic tests, suggest a complex interplay of cardiac, gastrointestinal, and possibly neurological factors. The following differential diagnoses are organized into categories:
Single Most Likely Diagnosis
- Esophageal Dysmotility: The patient's symptoms of dysphagia, particularly with certain foods, difficulty initiating the swallow mechanism, and food getting stuck at the epiglottis, as shown on the barium swallow study, strongly suggest esophageal dysmotility. This condition can be related to the patient's history of GERD and hiatal hernia, which may cause inflammation and swelling of the esophageal linings, further impairing motility.
Other Likely Diagnoses
- Gastroparesis: Although primarily associated with gastric motility issues, gastroparesis can sometimes contribute to or exacerbate symptoms of dysphagia and swallowing difficulties, especially if there is a significant delay in gastric emptying.
- Cardiac-Related Dysphagia: The patient's history of tachycardia and benign bundle branch block, along with symptoms occurring during exercise, might suggest a cardiac component to the dysphagia, possibly related to vasovagal responses or other cardiac dysrhythmias that could be exacerbated by exercise or stress.
- Eosinophilic Esophagitis: Given the patient's history of GERD and symptoms of dysphagia, eosinophilic esophagitis should be considered, especially if the inflammation and swelling noted on ENT evaluation are not fully explained by GERD alone.
Do Not Miss Diagnoses
- Achalasia: A rare but important condition to rule out, given the patient's dysphagia and difficulty swallowing. Achalasia is characterized by the inability of food to pass through the esophagus and into the stomach, often due to abnormal muscle contractions.
- Esophageal Cancer: Although less likely given the patient's age and presentation, esophageal cancer can cause dysphagia and should be considered, especially if there are risk factors such as a long history of GERD.
- Myasthenia Gravis: This autoimmune disorder can cause muscle weakness, including the muscles used for swallowing, leading to dysphagia. The patient's symptoms of numbness, tingling, and episodic nature of symptoms could potentially be related to myasthenia gravis, although this would be less common.
Rare Diagnoses
- Rumination Syndrome: Characterized by the involuntary regurgitation of food, which can then be chewed and swallowed again. While not directly suggested by the patient's symptoms, it could be considered in the differential for dysphagia and swallowing difficulties.
- Esophageal Spasm: Abnormal contractions of the esophagus can cause chest pain and dysphagia. While the patient's symptoms do not strongly suggest esophageal spasm, it remains a possibility in the broad differential diagnosis of esophageal disorders.