Clinical Diagnosis of Esophageal Dysphagia Using Transnasal Esophagoscopy: A Case Report

Introduction

Difficulty in swallowing is known as dysphagia and the term odynophagia is often referred to painful swallowing. Dysphagia is a disorder that is becoming more widespread. It is most commonly seen in individuals aged above 50 years. The three types of dysphagia clinically are oral dysphagia, pharyngeal dysphagia and esophageal dysphagia. Mastication issues, lubrication related, tongue weakness, cleft palate, lesions of buccal cavity and anomaly in floor of the mouth are few causes of oral dysphagia. Obstructing lesions of pharynx, paralysis of vocal folds, and inflammatory conditions are few examples for cause of pharyngeal dysphagia. Additionally, increased prevalence of degenerative diseases and neuromuscular disorders associated with aging may cause pharyngeal dysphagia [1]. Few causes of esophageal dysphagia are lumen obstruction, thyroid lesions, and lesions on the wall of esophagus [2]. Moreover, the two major identified causes of esophageal dysphagia are (i) structural disorders and (ii) motility disorders [1]. A few structural causes of esophageal dysphagia include mucosal rings and webs, intra- and extra mural inflammatory lesions and/or fibrotic strictures and carcinoma of esophagus. Further, esophageal dysphagia of motility type is caused by achalasia and achalasia like disorders.

The presence of dysphagia needs to be assessed thoroughly from careful case history. A detailed case history is of paramount importance that guides further investigation process. Studies have reported that in 80% of cases, likely the anatomical site of lesion and probable cause of dysphagia can be determined from good history [3]. In most cases, the history reveals three important factors; (a) presence or absence of dysphagia; (b) site of the problem at pharyngeal or esophageal level; (c) distinguish between structural abnormality and motor disorder.

The following temporal and other related issues would aid in differentiation of different dysphagias from case history. Symptoms onset, symptoms duration and progression of dysphagia would provide useful information. For example: short history of progressive dysphagia associated with weight loss hints malignancy [3]. The presence of retrosternal bolus hold up suggests oesophagus could be the site of lesion. Whereas, delayed initiation of swallow, nasal regurgitation of fluid during swallow, cough while swallow indicative of aspiration and repeated swallow to satisfactorily clear the swallowed food material are four symptoms that suggestive of oro-pharyngeal dysphagia [1].

Case Presentation

A 72 years old male (named ‘G’) reported with a complaint of imbalance while walking since 2 months to Neurology outpatient department of a tertiary hospital. Difficulty in swallowing foods was reported since 15 days along with upper limb weakness since 2 days back. Routine CNS examination, orientation, consciousness and so on were assessed and referred further to Department of Laryngology for swallowing assessment.

In the Department of Laryngology, a detailed case history followed by clinical assessment of swallowing was done. Three complaints that were significant from the reported history from patient ‘G’ were; (a) weight loss in the last 15 to 20 days; (b) difficulty in swallowing, in general and pain or discomfort in chest, in specific and, (c) sudden onset of swallowing complaints. Case history also revealed that the client was on regular diet orally.

Informal swallowing assessment revealed that client ‘G’ had ‘cleared’ the manual 3 finger test, oral peripheral mechanism examination found to be normal and adequate in terms of structure and function. The client ‘G’ had passed in dry swallow, saliva and water swallow screening tests. No change in voice quality noticed after water swallow test. Adequate hyo-laryngeal elevation noted manually during dry and saliva swallow tests. Further, ‘G’ was recommended for FEES examination as part of routine objective evaluation.

After obtaining written consent from client ‘G’, fiber-optic endoscopic evaluation of swallowing (FEES) procedure was performed by using Digital Swallowing Lab (Model 7120) of KayPENTAX (New Jersy, USA) to assess swallowing related complaints. The velopharyngeal closure, pharynx including base of tongue, epiglottis, vallecula, posterior and lateral pharyngeal walls, lateral channels, pyriform sinus were carefully examined after the scope was inserted. Aryepiglottic folds, interarytenoid space, both true as well as false vocal folds, subglottis, and proximal trachea of the larynx and supraglottis were also thoroughly examined. Further, the retroflexion of epiglottis on dry swallow was normal and no secretions were noticed in the laryngo-pharyngeal structures before introduction of any liquid or food noticed in client ‘G’.

Synthetic food coloring agent or dye was mixed with water for clear liquid, milk for thin liquid, curd for semi solid, smashed banana for soft solid and biscuits for solid that suits the Indian context and cultural settings, were used as bolus presentation one after the other by varied quantity in terms of half-a-teaspoon to full teaspoon and in terms of varied food bolus consistencies for safe and efficient swallowing function assessment. The above bolus presentation in terms of quantity and consistencies were practiced as a routine protocol at the tertiary hospital, which has been referred to as ‘DMH Protocol’. Swallowing scopy (FEES) findings revealed that the patient ‘G’ had mobile vocal folds bilaterally, adequate laryngeal elevation during swallowing, good clearance to all consistencies of bolus presentation from half teaspoon to full teaspoon at pharyngeal phase, absence of penetration and aspiration to any of the consistencies of bolus presented and laryngeal sensation and cough reflex were present.

In addition to the above, Functional Esophagoscopy using Transnasal Esophagoscopy (TNE) was employed to determine the esophageal phase of swallowing. It is known that TNE utilizes a working channel for suction, air insufflations & irrigation and it can be administered without sedation [4]. Introduction of high quality fiber-optic esophagoscope and distal chip permits easy assessment of esophagus as an office procedure. TNE has become an extremely effective tool in the inventory of otolaryngologists [5]. In client ‘G’, TNE procedure was performed in sitting position on a chair subsequent to normal swallow study at oral, and pharyngeal phases of swallowing. Results of TNE procedure indicated that lower part of esophagus had a growth or mass lesion. Figure 1 depicts the still images of swallowing function captured through TNE. Further, the client ‘G’ was recommended for biopsy, suspecting malignancy.

Discussion

An initial evaluation of patients with swallowing difficulties needs to be performed with a dysphagia team comprising of Speech-Language Pathologist (SLP), and Oto-Rhino-Laryngologist, if needed radiologist, nurse, dietitian, and gastroenterologist would also be serving as members of the team. SLPs gather detail medical and non-medical history, determine range of motion of oral structures, and measure functional phases of swallowing with various food materials. Few imperative information obtained in history are patient’s swallowing difficulties, patient’s respiratory and nutritional status, presence of tracheostomy tube (if any) and patient’s cognitive level [6].

Also, swallowing difficulty reported by client ‘G’ in terms of its nature, type and location are paramount significant to predict dyphagia types. Client ‘G’ reported retrosternal discomfort post swallow which indicated more of esophageal and less of pharyngeal dysphagia. The pharyngeal dysphagia is ruled out from the compliant of client ‘G’ as not mentioned any sort of ‘cough while swallowing’, ‘require multiple swallows to clear bolus in throat’, ‘food stuck during meal time’ or ‘lump or globus sensation in throat’ during meal time. The presence of retrosternal bolus hold up suggest that site of lesion would be esophagus [3]. The client ‘G’s history, in the present study correlated with literature findings [3].

Further, client ‘G’ reported discomfort in the retrosternum while swallowing for the ‘solid foods’ rather during liquid intake. Studies have proposed an algorithm to differentiate between esophageal disorders that caused dysphagia [1, 3]. The Cook’s [3] algorithm to identify structural lesion caused esophageal dysphagia is shown in Fig. 2. The presence of dysphagia symptoms in terms of three factors like ‘onset’, ‘duration’, and ‘consistency’ would help to determine useful diagnostic information more closely. Short history related to swallowing difficulty, sudden onset of swallowing problem, progressive symptoms, and consistent symptoms which were associated with weight loss are suggestive of esophageal dysphagia and more of “structural” rather than motor [3]. Another study also reported pain on swallowing or a persistent sore throat may indicate of cancer or malignancy [7]. The present client ‘G’s history related to the temporal and associated factors is in agreement with the results of previous studies [1, 3, 7].

Also, while swallowing, the client had normal velopharyngeal closure, adequate epiglottic inversion, and adequate white-out noted on FEES examination. Additionally, there was no residues post swallow and no penetration and aspiration suggested normal pharyngeal phase of swallowing for liquids and soft solids in client ‘G’. This directed to precede the investigation of esophageal phase of swallowing using Functional Esophagoscopy (FE) in the same evaluation sitting. As client ‘G’ was well tolerated for TNE procedure and a growth/mass lesion noted in the near lower end of the esophagus (see Fig. 1). The cause for the solid food ‘stuck’ in the retrosternal region would be associated with the presence of a growth in esophagus for client ‘G’. The present case report reaffirm the Cook’s (2008) algorithm with the additional usage of functional esophagoscopy (investigate the structure of esophagus without providing any food) in a single sitting to rule out the cause for retrosternal discomfort. Figure 3 shows the proposed algorithm to diagnose clients with esophageal dysphagia of localized lesion.

Even in TNE procedure, if the client did not show any abnormality like mass or web or spasm or any stricture or any motor issues like motility in esophagus, then the client should be referred for further detailed investigations (as depicted in dashed line in Fig. 3). Instrumental endoscopy procedures like FEES and immediately followed by TNE reduced the waiting time for treatment and improved the decision-making skills in client ‘G’.

TNE is increasingly becoming a vital tool for evaluating and treating patients with head and neck cancer. TNE reduces the time, expenses, and complications associated with conventional panendoscopy by preclude the need for anesthesia and operating room facilities [4]. Additionally, there are no outright contraindications to TNE [8]. Owing to these advantages, TNE was preferred in client ‘G’ to examine the esophagus. The present study employed a single case and the conclusions drawn needs caution in generalization. Future direction would be the proposed algorithm needs to be verified with more number of cases. Table 1 depicts the different types of instrumental tools employed generally to evaluate swallowing and comparison made with TNE procedure.

Conclusions

It is crucial to obtain a thorough history from clients with dysphagia as the history directs towards additional investigations that could be performed or advised. The anatomical location and likely cause of dysphagia, most often predicted from properly taken case history. Transnasal esophagoscopy (TNE), a diagnostic and therapeutic tool for patients with reflux, globus, and dysphagia, is becoming more widely used in the field of otolaryngology. TNE, an objective assessment procedure used to screen and identify a mass lesion/growth present in esophagus in client ‘G’ without anesthesia and in an outpatient situation. Also, the algorithm of Cook’s (2008) in this report augments to deduct esophageal dysphagia in one assessment sitting. Further, this case report warrants practicing clinicians to develop clinical skills in terms of considering careful case history and correlate with instrumental findings which would enhance in offering timely patient care in terms of appropriate referral, assessment and management of esophageal dysphagia.

Author Contribution

N. B. Conception and design, data collection, and finalizing and supervision. V. S. D. Conception and design, manuscript editing. R. R Data collection, draft preparation and finalization of the draft.

Funding

No funding received in the preparation of manuscript.

Declarations