What is the best approach to manage pharyngeal dysphagia with elevated Rheumatoid Factor (RF)?

Management of Pharyngeal Dysphagia with Elevated Rheumatoid Factor

Patients with pharyngeal dysphagia and elevated rheumatoid factor should be referred to a speech-language pathologist for a comprehensive swallowing evaluation, including videofluoroscopic swallow study or fiberoptic endoscopic evaluation to guide appropriate treatment. 1

Diagnostic Approach

Initial Assessment

• Evaluate for clinical signs of aspiration:
  • Coughing/choking during or after eating
  • Wet voice quality after swallowing
  • Throat clearing after swallowing
  • Nasal regurgitation
  • Drooling from mouth 1

Required Diagnostic Studies

1. Videofluoroscopic Swallow Study (VFSS) - gold standard for evaluating pharyngeal phase of swallowing 1

   • Assesses bolus manipulation, tongue motion, hyoid and laryngeal elevation, pharyngeal constrictor motion
   • Can identify silent aspiration (occurs in 55% of patients who aspirate) 1
   • Should be performed with limited radiation exposure (approximately 1 minute total fluoroscopy time) 1

2. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) - alternative to VFSS 1

   • Can be performed at bedside
   • Provides direct visualization of pharynx and larynx before/after swallow

3. Chest radiograph - to evaluate for aspiration pneumonia or infiltrates 1

4. Rheumatologic workup - to assess disease activity of underlying autoimmune condition 2

Treatment Algorithm

1. Multidisciplinary Team Approach

• Assemble team including physician, speech-language pathologist, dietitian, and other specialists as needed 1
• This approach has been shown to significantly decrease aspiration pneumonia rates (from 6.4% to 0% in one study) 1

2. Compensatory Techniques (based on VFSS/FEES findings)

• Postural adjustments - chin-down, head-rotated, or head-tilted positions 1
• Swallowing maneuvers - supraglottic swallow, Mendelsohn maneuver 1
• Dietary modifications:
  • Thickened liquids if thin liquids cause aspiration
  • Soft, easily chewable foods
  • Proper pacing during meals 1

3. Medical Management

• Treat underlying rheumatologic condition with appropriate immunosuppressive therapy 2, 3
  • Corticosteroids in combination with other immune modulators are the mainstay of treatment for autoimmune dysphagia 3
  • Coordinate treatment with rheumatologist 3

4. Rehabilitation Approaches

• Voice therapy - especially for patients with concurrent muscle tension dysphonia 4

  • 1-2 therapy sessions weekly for 4-8 weeks
  • Vocal Function Exercises and Semi-Occluded Vocal Tract Exercises 4

• Swallowing therapy - to improve muscle strength and coordination 1

  • Regular reviews by speech-language pathologist for ongoing management 1

5. For Severe or Refractory Cases

• Consider enteral nutrition if significant aspiration risk or inadequate oral intake 1, 5

  • Gastrostomy placement should be considered earlier rather than later in progressive disorders 1

• Surgical intervention for intractable aspiration 1

  • Only after thorough evaluation confirms appropriate surgical candidacy

Special Considerations for Rheumatologic Disorders

Pharyngeal dysphagia with elevated RF is often associated with autoimmune disorders that affect the muscles, neuromuscular junction, or nerves involved in swallowing 2, 3:

• Mechanism of dysphagia: In rheumatologic conditions, dysphagia is more commonly due to impaired muscle contraction and reduced hyolaryngeal excursion rather than failed upper esophageal sphincter relaxation 6

• Warning signs requiring immediate attention:

  • Unintentional weight loss
  • Recurrent respiratory infections
  • Signs of aspiration pneumonia 1

• Monitoring: Regular follow-up with speech-language pathologist to assess for changes in swallowing function as rheumatologic disease activity fluctuates 1

Pitfalls to Avoid

1. Relying solely on patient-reported symptoms - silent aspiration is common and occurs in 55% of patients who aspirate 1

2. Assuming cricopharyngeal myotomy will help all patients - this may be contraindicated if upper esophageal sphincter relaxation is normal 6

3. Delaying instrumental assessment - early VFSS or FEES is crucial for proper diagnosis and treatment planning 1

4. Focusing only on swallowing without treating underlying rheumatologic condition - coordinated care with rheumatology is essential 2, 3

5. Overlooking nutritional status - monitor weight, hydration, and nutritional parameters 1