An 82-year-old man is brought to the hospital with 3 days of fever, productive cough, and shortness of breath. He was admitted to the hospital 2 months ago with right lower lobe pneumonia. His wife reports that he coughs, chokes, and has nasal regurgitation when swallowing liquids or solids. The patient admits the food "gets stuck" in his throat when swallowing. He has a history of hypertension, type 2 diabetes, ischemic stroke, chronic kidney disease, coronary artery disease, and advanced dementia. His temperature is 38.7 C (101.7 F), blood pressure is 142/90 mm Hg, pulse is 104/min, and respirations are 20/min. Neck examination shows midline trachea without palpable masses. Lung examination shows crackles in the right lower lung field. Abdomen is soft and nontender. Chest imaging reveals right lower lobe pneumonia without additional mass lesions. Which of the following is the most appropriate next step in management of this patient's dysphagia?

Question

An 82-year-old man is brought to the hospital with 3 days of fever, productive cough, and shortness of breath.  He was admitted to the hospital 2 months ago with right lower lobe pneumonia.  His wife reports that he coughs, chokes, and has nasal regurgitation when swallowing liquids or solids.  The patient admits the food "gets stuck" in his throat when swallowing.  He has a history of hypertension, type 2 diabetes, ischemic stroke, chronic kidney disease, coronary artery disease, and advanced dementia.  His temperature is 38.7 C (101.7 F), blood pressure is 142/90 mm Hg, pulse is 104/min, and respirations are 20/min.  Neck examination shows midline trachea without palpable masses.  Lung examination shows crackles in the right lower lung field.  Abdomen is soft and nontender.  Chest imaging reveals right lower lobe pneumonia without additional mass lesions.  Which of the following is the most appropriate next step in management of this patient's dysphagia?

Quizplus · Accepted Answer

11ec25c8_d3da_2b7f_bc81_4de23f356c1e_MD0003_00 Dysphagia can be classified as oropharyngeal or esophageal. Oropharyngeal dysphagia presents with difficulty initiating swallowing due to inability to properly transfer food from the mouth to the pharynx. Underlying etiologies for oropharyngeal dysphagia can include stroke, advanced dementia, oropharyngeal malignancy, or neuromuscular disorders (eg, myasthenia gravis). Patients with oropharyngeal dysphagia can also have associated coughing, choking, or nasal regurgitation on swallowing. Other complications can include aspiration pneumonia and weight loss. This patient's history of stroke with coughing and choking on swallowing suggests oropharyngeal dysphagia. Recurrent right lower lobe pneumonia suggests likely aspiration pneumonia. Videofluoroscopic modified barium swallow study is preferred initially in these patients to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration. (Choices A and B) Proton pump inhibitors can be used for treatment of typical gastroesophageal reflux disease (GERD). Obtaining 24-hour pH monitoring might be helpful in confirming a diagnosis of GERD. However, this patient's dysphagia associated with coughing and choking along with his history of stroke and recurrent aspiration pneumonia require barium swallow to evaluate for oropharyngeal dysphagia. (Choices C and D) Esophageal motility studies and upper gastrointestinal endoscopy are typically used for evaluating esophageal dysphagia, which presents with a sensation of food getting stuck in the esophagus (not throat) a few seconds after a swallow but does not cause difficulty initiating swallowing. This patient's findings are more concerning for oropharyngeal dysphagia. Educational objective: Oropharyngeal dysphagia presents as difficulty initiating swallowing associated with coughing, choking, aspiration, or nasal regurgitation. Typically, patients are evaluated initially with videofluoroscopic modified barium swallow to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration. References: Role of barium esophagography in evaluating dysphagia. (http://www.ncbi.nlm.nih.gov/pubmed/19188476)

An 82-Year-Old Man Is Brought to the Hospital with 3