What is the approach to evaluating dysphagia in adults?

Evaluation of Dysphagia in Adults

The evaluation of dysphagia should begin with distinguishing between oropharyngeal and esophageal causes, followed by appropriate instrumental assessment with videofluoroscopy or endoscopy based on suspected location of the problem. 1

Initial Classification and Assessment

• Dysphagia affects up to 22% of adults in primary care settings and is more common in older adults, with those over 65 accounting for up to two-thirds of all cases 1, 2
• The first step is to determine whether the dysphagia is oropharyngeal or esophageal based on clinical presentation 1, 3
• Oropharyngeal dysphagia presents with difficulty initiating swallowing, nasal regurgitation, coughing during swallowing, and risk of aspiration 1
• Esophageal dysphagia presents with sensation of food sticking in the chest or throat after swallowing has been initiated 1, 4

History and Clinical Evaluation

• Assess for specific symptoms: coughing while swallowing, nasal regurgitation, wet vocal quality after swallowing, poor secretion management, weak cough, or feeling of food getting stuck 1, 2
• Evaluate lip closure, saliva pooling, tongue strength and mobility, chewing capacity, palatal movement, cough quality, and phoniatric function 1, 2
• For esophageal dysphagia, note whether it occurs with solids, liquids, or both:
  • Dysphagia that begins with solids and progresses to include liquids suggests mechanical issues (tumors, strictures) 1
  • Dysphagia for both solids and liquids from onset suggests motor problems (achalasia) 1, 4

Screening Tools

• Use structured questionnaires such as EAT-10, which has high discriminatory ability to identify patients with unsafe airway protection (sensitivity 86%, specificity 76%) 1, 2
• Perform water swallow tests or Volume-Viscosity Swallowing Test (V-VST), which has 92% sensitivity and 80% specificity for detecting dysphagia compared to videofluoroscopy 1, 2
• Discontinue use of non-validated dysphagia screening tools 5

Instrumental Assessment

For Oropharyngeal Dysphagia:

• Modified Barium Swallow (Videofluoroscopy): First-line instrumental assessment that evaluates the oral cavity, pharynx, and cervical esophagus 1

  • Assesses bolus manipulation, tongue movement, hyoid and laryngeal elevation, soft palate elevation, pharyngeal constrictor movement, epiglottic tilting, laryngeal penetration, and cricopharyngeal muscle function 2
  • Should be performed in conjunction with a speech therapist 1

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES):

  • Can be performed at bedside and involves transnasal passage of a flexible nasopharyngoscope to directly observe the pharynx and larynx before and after swallowing 1, 2
  • Particularly useful for patients who cannot be transported for videofluoroscopy 1

For Esophageal Dysphagia:

• Barium Esophagram:

  • Detects structural and functional abnormalities of the esophagus including esophagitis, strictures, rings, and carcinoma 2, 6
  • Has 96% sensitivity for diagnosing esophageal or gastroesophageal junction cancer 2

• Upper GI Endoscopy:

  • Allows direct visualization and biopsy of esophageal mucosa 3, 4
  • Essential for evaluating eosinophilic esophagitis, which is now a dominant cause of esophageal dysphagia 4
  • Standard practice includes obtaining esophageal biopsies during endoscopy for dysphagia evaluation 4

• Esophageal Manometry:

  • Particularly useful to confirm specific motor disorders such as achalasia 3, 4
  • High-resolution manometry (HRM) with Chicago Classification provides systematic diagnosis of esophageal motility disorders 4

Special Considerations

• Be aware that silent aspiration (aspiration without protective cough reflex) occurs in 55% of patients who aspirate 1, 2
• For patients with both oropharyngeal and esophageal dysphagia, consider combined videofluoroscopic swallow study with barium swallow 1
• In patients with unexplained oropharyngeal dysphagia, the combination of videofluoroscopy and static pharyngeal imaging with esophageal examination has higher diagnostic value than either study alone 2
• Immediate endoscopy is indicated for patients unable to tolerate sufficient liquid diet with continued dehydration, profound weight loss, or foreign body/food impaction with inability to tolerate secretions 2

Common Causes to Consider

• Oropharyngeal dysphagia: stroke, head and neck cancer, progressive neurologic diseases (dementia, ALS, Parkinson's) 1
• Esophageal dysphagia: esophagitis, achalasia, esophageal strictures, Zenker's diverticula, eosinophilic esophagitis, malignancy 1, 4
• Medication-induced dysphagia: anticholinergics, botulinum toxin (can cause excessive weakness, dysphagia, and aspiration pneumonia) 1, 7
• Age-related changes: sarcopenia affecting swallowing muscles, decreased tongue force generation, slower mastication, reduced salivary flow 1