What is the appropriate evaluation and management for a patient with a cough, difficulty swallowing (dysphagia), shortness of breath (dyspnea), and adenopathy, considering potential underlying conditions such as malignancy or opportunistic infections?

Evaluation and Management of Cough, Dysphagia, Dyspnea, and Adenopathy

This constellation of symptoms—particularly the combination of adenopathy with respiratory symptoms and dysphagia—requires urgent evaluation for malignancy, with immediate chest radiography and referral to speech-language pathology for swallowing assessment while simultaneously pursuing diagnostic workup for the underlying cause of adenopathy.

Immediate Diagnostic Priorities

Chest Radiography and Malignancy Screening

• Obtain a chest radiograph immediately to rule out lung cancer, mediastinal masses, infiltrates, or structural abnormalities that could explain both the adenopathy and respiratory symptoms 1, 2.
• In patients with risk factors for lung cancer (smoking history) or adenopathy suggesting possible metastatic disease, chest radiography is the essential first step 1.
• If the chest radiograph shows mediastinal lymphadenopathy or pulmonary nodules, particularly in a patient with hemoptysis or progressive symptoms, bronchoscopy is indicated even if initial imaging appears relatively normal 1.

Critical History Elements

• Ask specifically about ACE inhibitor use, as this is a common and immediately reversible cause of chronic cough that should be discontinued regardless of temporal relationship to symptom onset 2, 1.
• Document smoking status and pack-year history, as this significantly elevates lung cancer risk 1.
• Assess for medication history including β-adrenergic blocking agents that may exacerbate respiratory symptoms 2.

Vital Signs and Physical Examination

• Measure respiratory rate, heart rate, oxygen saturation, and blood pressure 2.
• A respiratory rate >35 breaths/min indicates severe respiratory compromise and is a contraindication for swallowing evaluation until stabilized 1, 2.
• Examine for dysarthria, dysphonia, weak voluntary cough, drooling, or inability to manage oral secretions—all clinical signs predicting aspiration risk 1.

Swallowing Evaluation Protocol

Immediate Referral Criteria

• Refer immediately to a speech-language pathologist (SLP) for comprehensive swallowing evaluation given the combination of cough and dysphagia 1, 3.
• The presence of cough associated with eating or drinking, combined with dysphagia, places this patient at high risk for aspiration and aspiration pneumonia 1.
• Question the patient and caregivers specifically about coughing while eating or drinking, fear of choking, and perceived swallowing problems—these subjective reports have 88% sensitivity for aspiration 1.

Instrumental Assessment

• Patients with dysphagia should undergo videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to identify aspiration risk and determine appropriate treatment 1, 3.
• Bedside clinical evaluation alone is insufficient—instrumental assessment is essential to detect silent aspiration (aspiration without cough reflex), which occurs in 55% of patients who aspirate 3.
• VSE or FEES not only diagnoses aspiration but determines which specific compensatory strategies enable safe swallowing 1.

High-Risk Conditions Assessment

• Obtain a medical history specifically directed at conditions increasing likelihood of oral-pharyngeal dysphagia: stroke, Parkinson disease, dementia, ALS, multiple sclerosis, head/neck cancer, or prior radiation therapy 1, 3.
• Assess for malnutrition, unintentional weight loss, or dehydration—these may indicate chronic aspiration 1.

Adenopathy Workup

Malignancy Evaluation

• The combination of adenopathy with cough, dyspnea, and dysphagia raises significant concern for thoracic malignancy (lung cancer, lymphoma, or metastatic disease causing mediastinal compression) 4.
• If chest radiograph shows mediastinal lymphadenopathy or pulmonary nodules, proceed to bronchoscopy with endobrachial ultrasound-guided biopsy for tissue diagnosis 4.
• For smokers with hemoptysis and adenopathy, bronchoscopy is indicated even when chest radiograph findings are normal 1.

Differential Considerations

• Consider infectious causes (tuberculosis, fungal infections), inflammatory conditions (sarcoidosis), and malignancy (lung cancer, lymphoma, metastatic disease) 4.
• Obtain bacterial, fungal, and mycobacterial cultures if lymph node sampling is performed 4.

Management Based on Underlying Etiology

If Malignancy is Identified

• For stage I-II non-small cell lung cancer, surgical resection is the treatment of choice; if cough was caused by surgically removable NSCLC, cough typically resolves 1.
• For advanced NSCLC (stages III-IV), external beam radiation and/or chemotherapy should be offered 1.
• For endobronchial tumors causing dyspnea or hemoptysis, endobronchial methods may palliate symptoms, though cough alone rarely justifies such treatment 1.
• Use centrally acting cough suppressants (dihydrocodeine, hydrocodone) for symptomatic relief in patients with lung cancer and cough 1.

Aspiration Management

• Patients with confirmed dysphagia should be managed by multidisciplinary teams including physician, nurse, SLP, dietitian, and physical/occupational therapists 1.
• Dietary recommendations should be prescribed based on VSE or FEES findings, testing with foods and liquids simulating normal diet 1.
• Patients with reduced level of consciousness are at extremely high risk for aspiration and should not be fed orally until consciousness improves 1.
• For patients with intractable aspiration despite conservative measures, surgical intervention may be considered 1.

Common Pitfalls and Caveats

• Do not delay malignancy workup while pursuing empiric treatment for common causes of chronic cough when adenopathy is present—this constellation demands urgent evaluation 1, 4.
• Do not rely solely on bedside swallowing assessment; instrumental testing is essential to detect silent aspiration, particularly in older adults who have higher rates of silent aspiration 3.
• Do not perform swallowing assessments on patients with altered mental status or severe respiratory distress (respiratory rate >35 breaths/min) until stabilized 1, 2, 3.
• Empiric steroid treatment for presumed sarcoidosis without tissue diagnosis can delay cancer diagnosis and worsen outcomes 4.
• The subjective assessment of voluntary cough as the sole predictor of aspiration is unreliable due to poor reliability and unclear association with actual aspiration 1.