What is the recommended workup for a patient presenting with dysphagia (difficulty swallowing)?

Recommended Workup for Dysphagia

The recommended workup for dysphagia should begin with endoscopy (OGD) with esophageal biopsies to rule out mucosal and structural disorders, followed by appropriate instrumental assessment based on whether symptoms suggest oropharyngeal or esophageal dysphagia. 1

Initial Evaluation

• Distinguish between oropharyngeal and esophageal dysphagia based on symptoms:

  • Oropharyngeal dysphagia: difficulty initiating swallowing, coughing, choking, or aspiration 2, 3
  • Esophageal dysphagia: sensation of food getting stuck after swallowing 2, 3

• Consider timing of symptoms:

  • Dysphagia for solid food that progresses to include liquids suggests mechanical issues (tumor, stricture) 1
  • Dysphagia for both solids and liquids from onset suggests motor problems (achalasia) 1

First-Line Diagnostic Tests

• Esophagogastroduodenoscopy (OGD) with biopsies at two levels in the esophagus to exclude eosinophilic esophagitis and other mucosal or structural causes 1

  • OGD has high diagnostic yield (54% of patients with dysphagia have major abnormalities) 1
  • Biopsies are essential even with normal-appearing mucosa 1, 2

• Barium swallow/esophagram when endoscopy is not possible or when structural disorders require further evaluation 1, 2

  • Biphasic esophagram evaluates the entire esophagus and gastric cardia 2
  • Can detect functional abnormalities not visible on endoscopy 4

Specialized Testing Based on Dysphagia Type

For Oropharyngeal Dysphagia:

• Videofluoroscopic Swallow Study (VFSS) or Modified Barium Swallow:

  • Gold standard for evaluating oral and pharyngeal phases of swallowing 2, 5
  • Assesses bolus manipulation, tongue motion, pharyngeal elevation, and laryngeal penetration 2
  • Should include various food consistencies simulating normal diet 1

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES):

  • Alternative to VFSS for direct visualization of swallowing mechanism 2
  • Can be performed at bedside for patients unable to travel to radiology 6
  • Useful for determining compensatory strategies to enable safe swallowing 1

For Esophageal Dysphagia:

• High-Resolution Manometry (HRM):

  • Indicated when endoscopy is normal but symptoms persist 4
  • Superior to standard manometry for detecting motility disorders 4
  • Provides information on achalasia subtypes which predicts clinical outcomes 1
  • Can be combined with impedance to visualize bolus movement 4

• Additional Testing:

  • Challenge swallows with larger water volumes or solid/viscous foods may unmask pathologies not seen with standard water swallows 4
  • Scintigraphy may assess esophageal transit and evaluate motility abnormalities 2

Special Considerations

• Abnormalities in mid or distal esophagus can cause referred dysphagia to the pharynx, so the entire esophagus should be evaluated even with apparent oropharyngeal symptoms 2, 4

• Silent aspiration (without protective cough reflex) occurs in up to 55% of patients who aspirate, making clinical diagnosis difficult 7

• In older adults, consider using structured questionnaires:

  • EAT-10 (Eating Assessment Tool): 86% sensitivity, 76% specificity for identifying aspiration risk 2, 7
  • Volume-Viscosity Swallowing Test (V-VST): 92% sensitivity, 80% specificity for detecting dysphagia 2, 7

• Assess for malnutrition and dehydration, which are common complications of dysphagia 8

  • Monitor weight loss (>10% indicative of malnutrition) 2
  • Evaluate hydration status regularly 8

Management Considerations

• Dietary modifications based on instrumental evaluation findings:

  • Thickened liquids reduce aspiration compared to thin liquids 1
  • Specific food consistencies should be tested during VFSS or FEES 1

• For patients with muscular weakness during swallowing, consider referral for:

  • Swallowing exercises (e.g., Shaker exercise, Masako technique) 1
  • Postural maneuvers, which can eliminate aspiration in 77% of patients 1

• Involve a speech-language pathologist (SLP) when oropharyngeal dysphagia is suspected 1, 3

• For frail older adults with progressive neurologic disease, dysphagia diagnosis should prompt discussion about goals of care 3