Dr. Amin said the type of evaluation depends on the type of swallowing difficulty. “I think there’s a fair understanding that if you have a liquid food dysphagia, FEES is a very, very good tool for that,” he said. “For solid food dysphagia, FEES is not a very good tool.”
Explore This IssueNovember 2013
Dr. Lintzenich said the location of the suspected swallowing problem has to guide which diagnostic tests you order. But, she added, “When a patient feels food sticking in the throat, a third of the time the problem is in the esophagus,” and the patient is just unable to pinpoint the location.
Dr. Postma emphasized that good speech pathologists interested in swallowing are available if they’re sought out. “When you’ve got speech therapists, not just in voice but in swallowing, your results and your patient outcomes are going to be remarkably better than if you try to go that kind of thing alone.”
Dr. Amin said asking the patient where the problem is might not be enough. “I think rather than going based upon where the patient sees the problem you should go based upon what type of bolus the patient is having a problem with,” he said. “A liquid bolus issue is going to happen more often with the pharynx, and you’re worried more about aspiration issues. If there’s a solid food issue, you’re going to probably focus more on the upper esophageal sphincter or the esophagus.”
However, Dr. Merati said, a problem with solids could also be another issue, such as poor tongue propulsion or a problem at the level of the vallecula.
In another case, a 56-year-old man had a problem with food sticking in his throat for two years, and it was worsening. He had no problem with liquids, no pneumonias or chest infections and no weight loss. There was some evidence of pharyngeal weakness.
Dr. Merati said the otolaryngologist would have to work closely with the speech language pathologist on the case, so it would help to have a good working relationship with the therapist. He wondered whether there was an underlying progressive neurologic problem in this patient or whether it might be related to an isolated event.
“You do need to be further assessing why this patient is having this problem,” Dr. Lintzenich said. “Even if this patient is 90 years old this is not normal to have a progression of pharyngeal weakness or tongue-based weakness, and you need to be evaluating that. At some point, you need to have a discussion with the patient about whether they should have a neurology evaluation.”