In a 78-year-old woman with intermittent foreign-body sensation in the lower throat and difficulty swallowing, for whom urgent care has ordered a CT scan of the throat and prescribed an antibiotic and prednisone, what is the appropriate next step in evaluation and management?

CT Scan of the Throat is NOT the Appropriate Initial Imaging Study for This Patient

For a 78-year-old woman with intermittent foreign body sensation and dysphagia, fluoroscopic evaluation (modified barium swallow or biphasic esophagram) is the imaging modality of choice, not CT scan. 1 The empiric prescription of antibiotics and prednisone without a clear diagnosis is premature and potentially harmful.

Why CT is Wrong Here

The ACR Appropriateness Criteria explicitly state that fluoroscopy remains the imaging modality of choice to evaluate dysphagia 1. CT scan does not assess the dynamic swallowing function that is critical in this clinical scenario. This patient's symptoms—intermittent foreign body sensation with food/pill feeling incompletely swallowed—suggest either:

• Oropharyngeal dysphagia (functional/motility issue)
• Structural abnormality requiring dynamic assessment
• Possible esophageal pathology with referred sensation

The Correct Diagnostic Approach

Step 1: Determine the Type of Dysphagia

This patient has unexplained oropharyngeal dysphagia based on her lower throat localization and sensation of incomplete swallowing 1. The ACR guidelines specify that these patients need detailed barium studies because:

• Distal esophageal or gastric cardia abnormalities can cause referred dysphagia to the throat 1
• The entire swallowing mechanism from oral cavity through gastric cardia must be evaluated

Step 2: Order the Right Imaging

A biphasic esophagram (barium swallow) should be the initial imaging study 1. This provides:

• Full evaluation of oral cavity, pharynx, esophagus, and gastric cardia
• Dynamic assessment of swallowing function
• Detection of structural abnormalities, strictures, or masses
• Assessment for aspiration risk

If functional/motility concerns predominate, a modified barium swallow with speech therapy may be more appropriate 1.

The Medication Problem

Prednisone is Unjustified and Risky

The empiric prescription of prednisone is concerning for multiple reasons:

There is no established indication 2. Prednisone dosing must be "individualized on the basis of the disease under treatment" 2, and no disease has been diagnosed here. The FDA labeling emphasizes that prednisone:

• Suppresses the immune system and increases infection risk 2
• Can mask signs of infection 2
• Should not be used without a clear diagnosis

In a 78-year-old patient, corticosteroids carry significant risks:

• Increased susceptibility to infections (particularly concerning given the concurrent antibiotic prescription) 2
• Potential for GI complications including peptic ulcers 2
• Metabolic derangements
• Adrenal suppression if used beyond short courses 2

Antibiotics are Also Premature

Without evidence of infection (fever, elevated white count, systemic symptoms), empiric antibiotics are not indicated. The concern for foreign body should be evaluated first with appropriate imaging.

Critical Differential Diagnoses to Consider

Based on the evidence, this presentation could represent:

1. Actual foreign body (food bolus, pill fragment) 3, 4, 5

   • Would be visible on barium study
   • May require endoscopic removal if confirmed

2. Globus pharyngeus 6

   • Benign but persistent sensation
   • Often related to GERD (which she may have given the pill sensation)
   • Responds to high-dose PPI therapy, not steroids

3. Structural abnormality (Zenker's diverticulum, web, stricture)

   • Common in elderly patients
   • Requires barium study for diagnosis

4. Esophageal dysmotility with referred sensation 1

   • Distal esophageal problems commonly refer to throat
   • Requires full esophageal evaluation

5. Malignancy (must be excluded in a 78-year-old with new dysphagia)

   • Barium study followed by endoscopy if abnormal

Recommended Management Algorithm

Immediate actions:

1. Hold the prednisone and antibiotics until a diagnosis is established
2. Order biphasic esophagram (barium swallow) as first-line imaging 1
3. Obtain careful history about:
   • Timing of symptoms relative to meals
   • Solid vs liquid dysphagia
   • Weight loss (red flag for malignancy)
   • GERD symptoms
   • Neurologic symptoms

Based on barium study results:

• If structural abnormality → endoscopy for tissue diagnosis
• If foreign body visualized → endoscopic removal 3, 4
• If normal study with persistent symptoms → consider modified barium swallow with speech therapy for functional assessment 1
• If suggestive of GERD/globus → trial of high-dose PPI 6

Common Pitfalls to Avoid

1. Don't assume "foreign body sensation" means actual foreign body - globus pharyngeus is far more common 6
2. Don't use CT as first-line imaging for dysphagia - it misses functional abnormalities and doesn't assess swallowing dynamics 1
3. Don't prescribe steroids empirically - they mask symptoms, increase infection risk, and have no role without a diagnosis 2
4. Don't ignore red flags - new dysphagia in a 78-year-old warrants thorough evaluation for malignancy
5. Don't forget that distal esophageal pathology refers to the throat - always evaluate the entire esophagus 1

The urgent care's approach reflects a shotgun strategy without proper diagnostic workup. Cancel the CT, hold the medications, and start with appropriate fluoroscopic evaluation.