A 56-year-old man comes to the physician due to several months of difficulty in swallowing. At first, meat would stick in his throat, and now he has difficulty swallowing all solid food and occasionally liquids. The patient coughs and sometimes aspirates food particles when eating. He has no shortness of breath, chest pain, or heartburn and has lost several pounds in the last 2 months. The patient was evaluated for persistent right ear pain 4 weeks ago, but no diagnosis could be made. His past medical history is significant for hypertension. He smokes 2 packs of cigarettes daily and consumes 6-8 bottles of beer on weekends. The patient is not sexually active. Lungs are clear to auscultation. Neck palpation shows no lymph node enlargement or thyromegaly. Which of the following is the best initial step in management of this patient?

Question

A 56-year-old man comes to the physician due to several months of difficulty in swallowing.  At first, meat would stick in his throat, and now he has difficulty swallowing all solid food and occasionally liquids.  The patient coughs and sometimes aspirates food particles when eating.  He has no shortness of breath, chest pain, or heartburn and has lost several pounds in the last 2 months.  The patient was evaluated for persistent right ear pain 4 weeks ago, but no diagnosis could be made.  His past medical history is significant for hypertension.  He smokes 2 packs of cigarettes daily and consumes 6-8 bottles of beer on weekends.  The patient is not sexually active.  Lungs are clear to auscultation.  Neck palpation shows no lymph node enlargement or thyromegaly.  Which of the following is the best initial step in management of this patient?

Quizplus · Accepted Answer

Explanation: Dysphagia (difficulty swallowing) is categorized into 2 main types: Oropharyngeal dysphagia is characterized by difficulty initiating a swallow, often accompanied by coughing, drooling, or aspiration Esophageal dysphagia is characterized by delayed sensations of food sticking in the upper or lower chest This patient's symptoms include recent ear pain (referred from a hypopharyngeal lesion), and coughing and aspiration during swallowing, which are all consistent with an oropharyngeal or proximal esophageal disorder. Dysphagia initially involving both solids and liquids would suggest a neuromuscular disorder, but dysphagia that occurs initially for solids and later includes liquids is characteristic of a mechanical obstruction. A number of his clinical features (eg, progressive symptoms, weight loss, history of alcohol and tobacco use) suggest a malignant cause of dysphagia. This patient has a structural lesion most likely located in the pharynx or proximal esophagus. The most reasonable first step would be to perform nasopharyngeal laryngoscopy, a minimally invasive test that can visualize this likely location. This pattern of dysphagia also can be evaluated using a standard barium esophagram, which will often identify upper esophageal disorders (eg, Zenker's diverticulum) and should be ordered prior to upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGD]). An esophagram is also indicated when there is suspicion for achalasia or a long-segment stricture (seen in patients with prior radiation exposure or caustic ingestion). If no diagnosis is made on laryngoscopy or barium esophagram, an EGD may be needed to visualize the esophageal mucosa fully. (Choice A) A CT chest scan may eventually be necessary to stage a malignancy found in the oropharynx/esophagus or to rule out extrinsic compression if other tests are nondiagnostic. However, CT chest scan has poor sensitivity for detecting small lesions or mucosal abnormalities in the pharynx and upper esophagus. (Choice B) Manometry may be helpful if an esophageal motility disorder is suspected. A mechanical obstruction is suggested due to this patient's pattern of dysphagia (initially beginning with solids and progressing to involve liquids). (Choice C) EGD is most helpful when a patient has lower-esophageal symptoms. EGD is not recommended as an initial evaluation for patients with possible upper-esophageal lesions as the upper esophagus is often not visualized well during scope insertion and perforation is possible. (Choice E) Videofluoroscopic barium swallow is a functional test providing visualization of the pharynx and upper esophagus as the patient swallows. This test assesses neuromuscular disorders but is less useful for identifying structural lesions than the direct visualization that laryngoscopy offers. Educational objective: Oropharyngeal dysphagia is characterized by difficulty initiating a swallow and often involves coughing, drooling, or aspiration. Esophageal dysphagia is characterized by delayed sensations of food sticking in the upper or lower chest. Structural lesions that lead to dysphagia in the pharynx and upper esophagus may be visualized with nasopharyngeal laryngoscopy. References: Diagnostic evaluation of dysphagia. (http://www.ncbi.nlm.nih.gov/pubmed/18542115)

A 56-Year-Old Man Comes to the Physician Due to Several