What is the differential diagnosis (ddx) for an 82-year-old female (YOF) with progressive dysphagia to both solids and liquids and a normal computed tomography (CT) scan of the head and neck?

Differential Diagnosis for Progressive Dysphagia to Solids and Liquids with Normal CT

In an 82-year-old woman with progressive dysphagia to both solids and liquids from the outset and normal head/neck CT, the primary differential is an esophageal motility disorder, most notably achalasia, rather than a structural lesion. 1

Key Diagnostic Principle

The pattern of dysphagia to both solids and liquids simultaneously from onset strongly suggests a motor/motility problem rather than a mechanical obstruction. 1 Progressive dysphagia that begins with solids only and later includes liquids indicates mechanical obstruction (tumor, stricture), whereas simultaneous involvement of both consistencies points to dysmotility. 1

Primary Differential Diagnoses

Esophageal Motility Disorders (Most Likely)

• Achalasia: The classic presentation for simultaneous solid and liquid dysphagia 1
• Diffuse esophageal spasm: Another primary motility disorder to consider 1
• Other esophageal dysmotility: Including aperistalsis or ineffective esophageal motility 1

Neurologic Causes (Oropharyngeal Component)

• Progressive neurologic disease: Parkinson's disease, dementia, or amyotrophic lateral sclerosis 1
• Prior stroke: Even remote cerebrovascular events can manifest with delayed dysphagia 1
• Age-related sarcopenia: Affecting swallowing muscles, though typically less severe 1

Structural Lesions (Less Likely Given Normal CT)

• Zenker's diverticulum: May not be well-visualized on standard CT 1
• Esophageal stricture: From chronic reflux or peptic disease 1
• Esophageal rings: Lower esophageal (Schatzki) rings 1
• Diffuse idiopathic skeletal hyperostosis (DISH): Cervical osteophytes causing esophageal compression 2

Inflammatory/Infiltrative Conditions

• Eosinophilic esophagitis: Though more common in younger patients, can occur in elderly 3
• Esophagitis: Reflux, medication-induced, or infectious (if immunocompromised) 1

Rare Vascular Causes

• Dysphagia lusoria: Aberrant right subclavian artery with thrombosis causing esophageal compression 4

Medication-Related

• Opioid-induced esophageal dysfunction: Increasingly recognized cause 3
• Anticholinergic medications: Common in elderly, can worsen dysphagia 1

Critical Next Steps in Evaluation

The appropriate next imaging study is a biphasic esophagram (barium swallow), which has 96% sensitivity for esophageal cancer and 80-89% sensitivity for motility disorders like achalasia. 1, 5

Why Biphasic Esophagram is Preferred

• Detects both structural abnormalities (strictures, rings, tumors) and functional abnormalities (motility disorders, reflux) 1
• Superior to endoscopy for detecting lower esophageal rings (95% vs 76% sensitivity) 1
• Videofluoroscopy can identify achalasia with characteristic beak-like distal narrowing 1
• More accurate than single-contrast studies for detecting subtle mucosal lesions 1

Role of Modified Barium Swallow

Do not order a modified barium swallow alone, as it only evaluates oropharyngeal function and does not assess the esophagus or gastric cardia, missing one-third of cases where esophageal pathology is the sole finding. 5 However, if both oropharyngeal and esophageal dysphagia are suspected, order a combined study with modified barium swallow plus complete esophageal imaging. 5

Subsequent Evaluation if Esophagram is Normal

• Esophagogastroduodenoscopy (EGD): To evaluate for mucosal lesions, obtain biopsies for eosinophilic esophagitis, and assess for subtle strictures 1, 3, 6
• High-resolution esophageal manometry: The definitive study for diagnosing motility disorders when structural causes are excluded 5, 7, 6

Important Clinical Pitfalls

Silent Aspiration Risk

55% of patients with aspiration have silent aspiration without protective cough reflex, making clinical examination alone insufficient. 5 Older adults have higher rates of silent aspiration than younger patients, reducing reliability of bedside evaluations. 1

Referred Dysphagia

Distal esophageal or gastric cardia lesions can cause referred dysphagia perceived in the pharynx or throat. 5 The esophagus and cardia must be carefully evaluated even when symptoms seem oropharyngeal. 1

Age-Related Considerations

In this 82-year-old patient, consider that sarcopenia affects swallowing muscles, xerostomia from medications is common, and polypharmacy (especially anticholinergics) can contribute significantly. 1 Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia. 3

Goals of Care Discussion

Before pursuing extensive workup, consider the patient's overall functional status and goals of care, particularly if progressive neurologic disease is suspected, as this significantly increases risk of aspiration pneumonia and malnutrition. 3 Speech-language pathologist consultation can provide structured assessment and recommendations for safe swallowing or palliative approaches. 3