What is the next best step in managing an elderly male with worsening dysphagia to solids over 72 hours and a normal Fibreoptic Nasal Endoscopy (FNE)?

Management of Elderly Male with Worsening Dysphagia to Solids and Normal FNE

The next best step is flexible oesophagoscopy (option c), as this patient presents with alarm symptoms (worsening dysphagia to solids) requiring urgent endoscopic evaluation to exclude structural and mucosal pathology, particularly malignancy, strictures, or eosinophilic esophagitis. 1

Rationale for Flexible Oesophagoscopy

• Upper endoscopy is explicitly indicated in patients with dysphagia, which is classified as an alarm symptom requiring prompt evaluation 1
• The American College of Physicians guidelines specifically state that upper endoscopy is indicated in men and women with heartburn and alarm symptoms including dysphagia 1
• Patients with dysphagia should preferably have endoscopy with oesophageal biopsies to rule out and treat mucosal and structural disorders prior to manometry 1
• Endoscopy allows direct visual inspection of the esophagus and enables histological sampling, which is critical for diagnosis 1

Why Not the Other Options?

Rigid Oesophagoscopy (Options a & e)

• Rigid oesophagoscopy is primarily a therapeutic procedure used for dilatation of strictures, not a first-line diagnostic tool 1
• There is no indication for urgent rigid oesophagoscopy in this case, as the patient has not yet had diagnostic evaluation of the esophagus itself 1
• Rigid procedures carry higher perforation risks, particularly in elderly patients 1

Barium Swallow (Option b)

• While barium swallow is useful and should be considered where endoscopy is not possible or where structural disorders require further scrutiny, it is not the preferred initial investigation 1
• Endoscopy is superior because it provides both visualization AND the ability to obtain biopsies, which is essential for diagnosing conditions like eosinophilic esophagitis, malignancy, or inflammatory conditions 1, 2
• Barium studies are best used as an adjunct to endoscopy, not as a replacement 2, 3

CT Chest (Option d)

• CT chest is not the appropriate next step for evaluating dysphagia when the upper aerodigestive tract examination (FNE) is normal 1
• Direct mucosal visualization and biopsy capability are needed first 1, 2

Critical Diagnostic Considerations

The 72-hour timeframe of worsening symptoms in an elderly patient raises concern for:

• Esophageal malignancy or stricture - particularly given the patient's age and progressive nature of symptoms 1
• Eosinophilic esophagitis - requires esophageal biopsies at two levels for diagnosis 1, 3
• Peptic stricture - from chronic reflux disease 1, 2
• Infectious esophagitis - particularly in elderly or immunocompromised patients 1
• Motility disorders - though these typically cause dysphagia to both solids and liquids 2, 3

Endoscopic Evaluation Protocol

During flexible oesophagoscopy, the endoscopist should:

• Obtain biopsies at two levels in the esophagus even if mucosa appears normal, to exclude eosinophilic esophagitis 1
• Carefully inspect for subtle mucosal changes, rings, strictures, or masses 1
• Document any structural abnormalities that may require subsequent therapeutic intervention 1

Common Pitfall to Avoid

Do not assume that a normal FNE excludes significant esophageal pathology. The FNE only visualizes the pharynx and larynx; it does not evaluate the esophagus where the pathology causing solid food dysphagia is most likely located 1, 2. The patient's symptom of dysphagia to solids specifically suggests an esophageal rather than oropharyngeal etiology 2, 3.

If Endoscopy is Normal

If flexible oesophagoscopy with biopsies reveals no structural or mucosal abnormality, then consider:

• Barium swallow to evaluate for subtle structural lesions or rings 1, 4
• High-resolution manometry if motility disorder is suspected, particularly with solid swallows to replicate symptoms 1
• Reassessment for oropharyngeal causes if symptoms persist 2