A 75-year-old man is evaluated for choking that started 3 months ago and has progressively worsened. He has trouble initiating the swallowing of pills and coughs when drinking liquids. He can eat soft foods without choking. He reports no heartburn, regurgitation, or chest pain. Parkinson disease was diagnosed 3 months ago. His only medication is carbidopa-levodopa.
On physical examination, vital signs are normal. A right, resting hand tremor, bradykinesia, rigidity, slow speech, and evidence of balance impairment are noted. The remainder of the examination is normal.
Which of the following is the most likely diagnosis?
B. Incarcerated paraesophageal hernia
C. Oropharyngeal dysphagia
D. Peptic stricture
MKSAP Answer and Critique
The correct answer is C. Oropharyngeal dysphagia. This content is available to MKSAP 19 subscribers as Question 56 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most likely diagnosis is oropharyngeal dysphagia (Option C), also called transfer dysphagia. Swallowing has three phases: oral phase (food bolus forms and transfers to the back of the throat), pharyngeal phase (bolus is safely positioned in the upper throat, the soft palate elevates, the epiglottis protects the trachea, the tongue moves backward, and the pharyngeal wall moves forward), and esophageal phase (bolus enters the esophagus with relaxation of the upper esophageal sphincter). When the first two phases fail to position a bolus in the throat for entry into the esophagus, choking, coughing, and nasal regurgitation of solids and liquids may occur. These symptoms pose a risk for aspiration pneumonia. Other presenting symptoms may include hoarseness (resulting from laryngeal nerve damage) and dysarthria (from weakness of the soft palate or pharyngeal constrictors), both suggesting an underlying neurologic disorder. Indeed, oropharyngeal dysphagia may be an early symptom or presenting sign of neurologic disorders, such as Parkinson disease and stroke. It is important to recognize oropharyngeal dysphagia by history because the initial recommended study is a modified barium swallow (with a range of liquid and solid consistencies) and videofluoroscopy. Endoscopy and esophageal manometry have a limited role in the evaluation of oropharyngeal dysphagia. Management consists of dietary changes and a swallowing exercise program.
Patients with achalasia (Option A) often have dysphagia with solids and liquids, along with nonacidic oral regurgitation of undigested food. Choking and aspiration are often late-stage symptoms that may occur after long-standing regurgitation and other dysphagia symptoms. This patient does not have any regurgitation and can swallow soft foods, making achalasia an unlikely diagnosis.
Incarcerated paraesophageal hernia (Option B) is often associated with pain and typically presents with solid dysphagia before liquid dysphagia. This patient has no chest pain and is experiencing liquid dysphagia; thus, incarcerated paraesophageal hernia is an unlikely diagnosis.
This patient is unlikely to have a mechanical obstruction, such as a peptic stricture (Option D), because he has more trouble swallowing liquids than solids. In addition, a peptic stricture is often more chronic, with gradual worsening.
- Common symptoms of oropharyngeal dysphagia include choking, coughing, and nasal regurgitation of solids and liquids.
- The initial evaluation of oropharyngeal dysphagia is a modified barium swallow (with a range of liquid and solid consistencies) and videofluoroscopy.