What diagnostic studies would you order for a patient with worsening dysphagia and a history of a neck tumor (neoplasm) on the left side that has been previously removed?

Diagnostic Studies for Dysphagia in a Patient with History of Left Neck Tumor

For a patient with worsening dysphagia and history of a previously removed left neck tumor, a neck CT or MRI with contrast should be ordered as the primary diagnostic study, followed by a targeted examination of the upper aerodigestive tract and a modified barium swallow. 1

Initial Imaging Approach

Primary Diagnostic Studies:

1. Neck CT or MRI with contrast 1

   • Strong recommendation per clinical practice guidelines
   • Provides detailed visualization of:
     • Potential tumor recurrence
     • Post-surgical changes
     • Lymph node status
     • Soft tissue involvement
   • Helps identify structural causes of dysphagia related to the previous tumor site

2. Targeted physical examination of the upper aerodigestive tract 1

   • Should include visualization of:
     • Larynx
     • Base of tongue
     • Pharynx
   • Can be performed via:
     • Flexible laryngoscopy
     • Mirror laryngoscopy
   • Essential to identify mucosal abnormalities that may not be visible on imaging

3. Modified barium swallow 1

   • Evaluates functional swallowing ability
   • Assesses both oral and pharyngeal phases of swallowing
   • Can identify:
     • Aspiration risk
     • Laryngeal penetration
     • Cricopharyngeal dysfunction
     • Bolus manipulation issues
   • Typically performed with a speech therapist

Secondary Diagnostic Studies

If initial studies are inconclusive or additional information is needed:

1. Fine-needle aspiration (FNA) 1

   • Strong recommendation for suspicious masses
   • Preferred over open biopsy
   • Provides tissue diagnosis with minimal invasiveness

2. Biphasic esophagram 1

   • Important because:
     • Abnormalities in distal esophagus can cause referred dysphagia to the neck
     • Patients with history of head/neck cancer have increased risk of synchronous esophageal lesions
     • Provides comprehensive evaluation of the entire esophagus

3. Examination under anesthesia (EUA) 1

   • Recommended if other tests don't yield a diagnosis
   • Allows direct visualization and biopsy of suspicious areas
   • Should be performed before any open biopsy

Important Considerations

• History of neck tumor significantly increases risk: Patients with previous head and neck cancer have higher risk of recurrence or second primary tumors 1

• Dysphagia severity assessment: The degree of dysphagia should be documented as it impacts management decisions and may indicate severity of underlying pathology 2

• Aspiration risk: Up to 55% of patients with dysphagia may have silent aspiration without protective cough reflex 1

• Location matters: Tumors previously located in the oral cavity or oropharynx are associated with higher risk of dysphagia complications 3

Common Pitfalls to Avoid

1. Assuming dysphagia is only from surgical changes: Always evaluate for tumor recurrence or new primary lesions

2. Focusing only on the previous tumor site: Evaluate the entire upper aerodigestive tract as dysphagia can be referred from distal sites

3. Relying solely on one imaging modality: Combination of functional and anatomical studies provides more comprehensive evaluation

4. Delaying diagnosis: Worsening dysphagia in a patient with history of head and neck cancer should be considered suspicious for recurrence until proven otherwise

5. Missing cystic masses: Continue evaluation of cystic neck masses as they may represent malignancy despite benign appearance 1