What is the approach to assess a patient with dysphagia in the emergency department?

Assessment of Painful Swallowing (Dysphagia) in the Emergency Department

A comprehensive dysphagia assessment in the emergency department should include a structured clinical evaluation followed by appropriate instrumental assessment, with videofluoroscopy or fiberoptic endoscopic evaluation of swallowing (FEES) being the preferred diagnostic methods for patients with unexplained or concerning symptoms. 1, 2

Initial Clinical Assessment

History Taking

• Determine location of symptoms:
  • Oropharyngeal dysphagia: sensation of food sticking in throat, coughing/choking during swallowing
  • Esophageal dysphagia: sensation behind sternum, may refer to throat 1, 3
• Assess for associated symptoms:
  • Coughing/choking during or after eating
  • Wet voice quality after swallowing
  • Nasal regurgitation
  • Drooling from mouth
  • Weight loss
  • Recurrent respiratory infections 2

Physical Examination

• Oral cavity assessment:
  • Lip closure and evidence of saliva pooling
  • Tongue strength, mobility, and tone
  • Chewing capacity
  • Palatal movement in response to tactile stimulation 1
• Neurological assessment:
  • Cranial nerve function
  • Facial and lateral jaw movements
  • Quality and strength of cough
  • Phoniatric function 1

Screening Tools

Structured Questionnaires

• EAT-10 (Eating Assessment Tool): High discriminant ability to identify patients who aspirate (sensitivity 86%, specificity 76%, negative predictive value 95%) 1

Bedside Swallow Tests

• Water swallow test: Patient drinks small amounts of water while clinician observes for signs of aspiration
• Volume-Viscosity Swallowing Test (V-VST): Uses different volumes and viscosities to assess swallowing function
  • High sensitivity (92%) and specificity (80%) compared to videofluoroscopy 1

Instrumental Assessment

When to Perform Instrumental Assessment

• Patients with positive screening results
• Unexplained oropharyngeal dysphagia
• Suspected silent aspiration
• Rapid deterioration of neurological disease
• Recent pneumonia or other signs of aspiration 1, 2

Preferred Instrumental Methods

1. Fiberoptic Endoscopic Evaluation of Swallowing (FEES):

   • Advantages: No radiation exposure, minimal patient cooperation required, can be performed at bedside, can be used as therapeutic feedback tool 1
   • Particularly useful for neurological causes of dysphagia

2. Videofluoroscopic Swallow Study (VFSS)/Modified Barium Swallow:

   • Gold standard for evaluating pharyngeal phase of swallowing
   • Assesses bolus manipulation, tongue motion, hyoid/laryngeal elevation, pharyngeal constrictor motion
   • Can identify silent aspiration, which occurs in 55% of patients who aspirate 1, 2

3. Biphasic Esophagram:

   • Recommended for unexplained oropharyngeal dysphagia
   • Important because distal esophageal or gastric cardia lesions can cause referred dysphagia to throat 1

Special Considerations for Specific Patient Populations

Stroke Patients

• 40-78% of acute stroke patients experience dysphagia
• Maintain nil per os status and hydration until dysphagia assessment is complete
• Assess for dysphagia after extubation in critically ill patients
• Implement interprofessional team approach using evidence-based protocols 1

Neurodegenerative Disease Patients (e.g., ALS, Parkinson's)

• Screen for dysphagia at diagnosis and during follow-up (every 3 months recommended)
• Evaluate both symptoms and clinical signs, even in absence of bulbar symptoms
• Consider medication side effects that may affect swallowing 1

Common Pitfalls to Avoid

• Relying solely on patient-reported symptoms: Silent aspiration is common (55% of patients who aspirate) 1, 2
• Failing to evaluate the entire esophagus: Distal lesions can cause referred pharyngeal symptoms 1
• Overlooking neurological causes: Many neurological conditions present with dysphagia before other symptoms become prominent 1
• Delaying instrumental assessment: Can lead to improper diagnosis and treatment planning 2
• Neglecting nutritional status: Dysphagia can lead to malnutrition, dehydration, and weight loss 1, 2

Management Decisions in the ED

• If aspiration risk identified:
  • Maintain nil per os status
  • Ensure adequate hydration via IV fluids
  • Consider nasogastric or small-bore feeding tube for medication access and nutrition 1
• Consult speech-language pathology for formal evaluation
• Consult dietitian for nutritional assessment
• Consider admission for patients with:
  • Signs of aspiration pneumonia
  • Severe dehydration or malnutrition
  • Inability to maintain adequate oral intake
  • Need for urgent intervention (e.g., foreign body, severe stricture) 1, 2

By following this structured approach to assessing dysphagia in the emergency department, clinicians can efficiently identify the cause of painful swallowing and implement appropriate management strategies to reduce morbidity and mortality associated with this condition.