What is the management approach for an elderly man with progressive dysphagia (difficulty swallowing) and solids getting stuck?

Management of Progressive Dysphagia with Solids Getting Stuck in an Elderly Man

The management of progressive dysphagia with solids getting stuck in an elderly man should begin with an urgent endoscopy with esophageal biopsies to rule out structural and mucosal disorders before considering other interventions. 1

Initial Diagnostic Approach

Urgent Endoscopic Evaluation

• Upper gastrointestinal endoscopy (OGD) with biopsy is the first-line investigation as it:
  • Allows direct visualization of the esophagus
  • Enables histological sampling for accurate diagnosis
  • Can detect mucosal abnormalities, strictures, masses, and other structural causes 1
  • Has a high diagnostic yield (54% of patients with dysphagia have major abnormalities detected) 1

Risk Assessment

• Progressive dysphagia with solids getting stuck in an elderly man raises significant concern for:
  • Esophageal malignancy (higher risk in older men)
  • Peptic stricture
  • Eosinophilic esophagitis
  • Achalasia or other motility disorders
  • Extrinsic compression 1

Diagnostic Algorithm

1. OGD with biopsy - First-line investigation
2. Barium swallow - If endoscopy is normal or inconclusive
3. Videofluoroscopic swallowing examination (VSE) or Fiberoptic endoscopic evaluation of swallowing (FEES) - To assess swallowing function and risk of aspiration 2
4. High-resolution manometry (HRM) - To assess esophageal motility if structural causes are ruled out 2
   • Should include solid swallows to replicate presenting symptoms 2

Management Strategies

Dietary Modifications

• Based on VSE or FEES findings, specific dietary recommendations should be prescribed:
  • Thickened liquids show dramatic reduction in aspiration compared to thin liquids 2
  • Spoon delivery is safer than cup drinking for liquids 2
  • Avoid straw drinking in elderly patients due to reduced airway protection 2
  • Test various food consistencies during VSE/FEES to determine safe options 2

Compensatory Strategies

• Postural techniques can eliminate aspiration in up to 77% of patients:
  • Chin-down, chin-up, head-rotated, head-tilted, or lying down positions 2
  • These should be determined during VSE or FEES to identify which is most effective 2

Swallowing Exercises

• Physiologic exercise programs to strengthen swallowing musculature:
  • Shaker exercise: Sustained and repetitive head lifts three times daily while supine 2
  • Masako technique: Tongue hold between teeth or lips paired with dry swallow 2
  • These exercises have shown significant improvement in swallowing function and resolution of aspiration 2

Nutritional Support

• For severe dysphagia with risk of malnutrition or dehydration:
  • Oral nutritional supplements (ONS) to increase energy, protein, and micronutrient intake 2
  • For severe neurological dysphagia, enteral nutrition (EN) may be necessary 2
  • Percutaneous endoscopic gastrostomy (PEG) is preferred over nasogastric tubes for long-term nutritional support 2

Hydration Management

• Dehydration is a frequent and serious complication in dysphagia:
  • Can lead to urinary tract infections, constipation, confusion, and worsening of chronic diseases 3
  • Requires careful monitoring of fluid intake
  • Use of thickened liquids and adapting texture and presentation of foods 3

Follow-up and Monitoring

• After initiation of therapy, follow-up endoscopy with biopsy is recommended to assess response 2
• Regular monitoring of nutritional status and hydration is essential 3
• Ongoing swallowing therapy until safe and sufficient oral intake is possible 2

Important Caveats

• Symptoms may not always correlate with histological or structural findings 2
• Skipping endoscopy and proceeding directly to manometry risks missing malignancy or structural abnormalities 1
• Multiple biopsies should be taken at different levels in the esophagus to exclude conditions like eosinophilic esophagitis 1
• Aspiration can be silent in up to 55% of cases, with an absent protective cough reflex 2