A case of isolated sudden onset Dysphagia.

Abstract

A 77-year-old man presented to hospital with a 3-week history of painless dysphagia with an associated 13 pound weight loss, initially described as trouble swallowing solids which progressed to include liquids. He denied problems with chewing, but reported difficulty pushing the food to the back of his throat and coughed with attempts to eat. He complained of saliva pooling and drooling. His past medical history was significant for colon cancer, coronary artery disease with bypass graft, hypertension, spinal stenosis, and glaucoma. He never smoked, did not consume alcohol, and had no family history of neurological disease. His neurological examination revealed dysarthria involving lingual sounds with 100 % intelligibility in conversation but was otherwise unremarkable. Blood work was unremarkable and head CT did not reveal any acute pathology. Cranial MRI revealed two old silent infarcts, as there was no history of stroke-like symptoms or signs, with no other significant findings. MRI of the cervical spine, neck X-ray, esophagogastroduodenoscopy, and esophageal manometry were unremarkable. Electromyography and nerve conduction studies were normal. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was scored using the Secretion Severity Rating Scale (SSRS) [1] and the Rosenbek Penetration Aspiration Scale (PAS) [2]. The patient was aspirating his own secretions and pyriform sinus residue scoring (6/8–7/8 on PAS) across textures (Video segment 1). Following the FEES assessment, a Videofluoroscopic Swallowing Study (VFSS) ruled out any impairment involving the upper esophageal sphincter (UES) that could affect bolus flow. The VFSS was scored using the PAS and Modified Barium Swallow Impairment Profile (MBSImP) [3]. There was difficulty initiating the swallow with multiple attempts to move the bolus posteriorly to trigger the pharyngeal swallow. Consistent with the FEES results, the patient remained at high risk of aspiration with all oral intake, scoring up to 4/8–7/8 on the PAS with bolus volumes larger than a teaspoon (Video segment 2).