What is the initial workup and treatment for a patient with difficulty swallowing (dysphagia)?

From the Guidelines

The initial workup for dysphagia should begin with a thorough screening for swallowing deficits using a valid screening tool by an expert in dysphagia, ideally a speech-language pathologist (SLP), as soon as the patient is alert and ready for trialing oral intake 1. This approach is crucial in identifying patients at risk for pharyngeal dysphagia or poor airway protection.

• The screening should be followed by a detailed bedside swallowing assessment and management of swallowing, feeding, nutritional, and hydration status by a speech-language pathologist, occupational therapist, dietitian, or other trained dysphagia clinician if the initial screening results are abnormal 1.
• A videofluoroscopic swallow study (VSS, VFSS, MBS) or fiberoptic endoscopic examination of swallowing (FEES) should be performed on all patients considered at risk for pharyngeal dysphagia or poor airway protection, based on results from the bedside swallowing assessment 1.
• Treatment depends on the underlying cause and may include restorative swallowing therapy, compensatory techniques, dietary modifications, and education on swallowing and feeding recommendations 1.
• Restorative swallowing therapy and/or compensatory techniques should be considered to optimize the efficiency and safety of the swallow, with reassessment as required 1. Key considerations in the management of dysphagia include:
• Reducing the risk of pneumonia by permitting and encouraging patients to feed themselves whenever possible and providing meticulous mouth and dental care 1.
• Dietary modifications, such as soft or pureed foods and thickened liquids, can reduce aspiration risk, and proper positioning during meals (sitting upright at 90 degrees) is also important 1.
• In severe cases, temporary or permanent feeding tube placement may be necessary if oral intake remains unsafe or inadequate for nutrition.

From the Research

Initial Workup for Dysphagia

The initial workup for a patient with difficulty swallowing (dysphagia) involves a series of diagnostic tests to determine the cause of the condition. These tests may include:

• Endoscopy to visualize the esophagus and identify any narrowing or obstruction
• Barium swallow study to evaluate the swallowing mechanism and identify any abnormalities
• High-resolution esophageal manometry (HRM) to assess esophageal motility and function 2
• Upper gastrointestinal (GI) endoscopy to examine the esophagus, stomach, and duodenum for any lesions or abnormalities 3

Treatment Options for Dysphagia

The treatment for dysphagia depends on the underlying cause and may include:

• Endoscopic dilation or injection of botulinum toxin for patients with dysfunction of the upper esophageal sphincter 4
• Pneumatic balloon dilation, injection of botulinum toxin, or peroral endoscopic myotomy for esophageal motility disorders 4, 2
• Endoscopic dilation for esophageal stricture, and intraluminal steroid injection or temporary stent for refractory benign esophageal stricture 4
• Self-expandable metal stent insertion for dysphagia with a malignant cause 4, 3
• Surgical interventions, such as laparoscopic Heller myotomy, for achalasia or other motility disorders 2

Predictors of Treatment Success

Several factors can predict the success of treatment for dysphagia, including:

• Age, with older patients responding better to treatment 2
• Sex, with females responding better to treatment than males 2
• Manometric type, with type II achalasia responding better to treatment than type III achalasia 2
• Presence of underlying conditions, such as gastroesophageal reflux disease (GERD) or peptic stricture 3