Can a Transesophageal Echocardiogram (TEE) be performed on a patient with dysphagia?

TEE in Patients with Dysphagia

TEE can be performed in patients with dysphagia, but it carries significantly increased risks and requires careful risk-benefit assessment, as dysphagia is a relative contraindication rather than an absolute one. 1

Risk Assessment Framework

When considering TEE in a patient with dysphagia, you must weigh the diagnostic necessity against the elevated complication risk:

Relative Contraindications to TEE

Dysphagia represents a relative contraindication to TEE because it indicates potential esophageal pathology or dysfunction that increases the risk of probe-related complications. 1 In one large series, 6 of 11 patients (55%) who failed esophageal intubation had a history of dysphagia. 2

When TEE is Strongly Indicated Despite Dysphagia

Proceed with TEE when it provides critical diagnostic information that cannot be obtained otherwise, particularly in these Class I scenarios:

• Acute, life-threatening hemodynamic instability unresponsive to treatment during cardiac surgery 3
• Suspected infective endocarditis with positive blood cultures or recent antibiotic therapy, where TEE is essential for detecting vegetations and complications 3
• Evaluation of prosthetic valve dysfunction during concomitant cardiac surgery 3

Alternative Approaches When TEE is Too Risky

Consider epicardial or epiaortic echocardiography when TEE is contraindicated or cannot be performed safely. 3 These modalities allow visualization under aseptic conditions during cardiac surgery and can identify structures like intraventricular thrombi when TEE images are inadequate or the procedure is too risky. 3

Specific Risks in Dysphagia Patients

Immediate Complications

• Failed esophageal intubation occurs in approximately 0.73% of general patients, but the rate is substantially higher (up to 55% of failed intubations) in those with pre-existing dysphagia 2
• Esophageal trauma or perforation risk is elevated, presenting with pain, breathlessness, fever, and tachycardia 4
• Pharyngeal injury from probe insertion is the most common minor complication 3

Post-Procedure Dysphagia Worsening

TEE significantly worsens swallowing function for at least 24 hours, even in patients without pre-existing dysphagia:

• In acute stroke patients, TEE caused significant increases in secretion severity scores and aspiration risk that persisted for 24 hours post-procedure 5
• The odds of developing new dysphagia after cardiac surgery are 7.8 times higher in patients who undergo TEE compared to those who do not, even after controlling for stroke, prolonged intubation, and operative duration 6
• In pediatric cardiac surgery, 18% developed dysphagia when TEE was used 7

Pre-Procedure Evaluation

Before proceeding with TEE in a dysphagia patient, document:

• Severity and etiology of dysphagia (structural vs. functional, oropharyngeal vs. esophageal)
• History of esophageal pathology: strictures, diverticula, varices, recent surgery, or radiation 1
• Cervical spine abnormalities that may impair probe passage 2
• Current aspiration risk and respiratory status 5

Procedural Modifications

If you proceed with TEE despite dysphagia:

• Use topical anesthetic spray to the oropharynx to reduce discomfort 8
• Administer intravenous conscious sedation to improve tolerance 8
• Have experienced operators perform the procedure, as operator inexperience is a documented cause of failed intubation 2
• Minimize probe manipulation time to reduce trauma risk 7
• Consider smaller probes if available, particularly in patients with known esophageal narrowing 7

Post-Procedure Monitoring

Observe closely for signs of esophageal perforation: persistent pain (not transient discomfort), breathlessness, fever, tachycardia, or subcutaneous emphysema. 4 If any of these develop:

• Obtain immediate chest X-ray looking for pneumomediastinum, pneumothorax, or pleural effusion 4
• Perform water-soluble contrast study if clinical suspicion persists despite normal chest X-ray 3
• Obtain surgical consultation emergently if perforation is confirmed 3

Monitor swallowing function for at least 24 hours post-procedure, as aspiration risk is significantly elevated during this period. 5 Consider keeping the patient NPO or on modified diet until swallowing safety is reassessed. 5

Key Clinical Pitfall

Do not assume transient chest pain after TEE is benign in dysphagia patients. While mild discomfort is common, persistent pain mandates immediate evaluation for perforation, as this population has higher baseline risk. 3, 4