Diagnostic Evaluation of Dysphagia

Initial Diagnostic Approach

The American College of Radiology recommends videofluoroscopy or modified barium swallow as the primary diagnostic test for dysphagia evaluation, as it can assess both oral and pharyngeal phases of swallowing, including bolus manipulation, tongue motion, pharyngeal elevation, and laryngeal penetration 1, 2
A biphasic esophagram should be performed to evaluate the entire esophagus and gastric cardia, as abnormalities in these areas can cause referred dysphagia to the pharynx 2, 3

For patients with suspected neurological causes of dysphagia, the ALS Functional Rating Scale-Revised (ALSFRS-R) or ALS Swallowing Severity Scale (ALSSS) can be used for assessment 4, 5
Structured questionnaires, such as the EAT-10 (Eating Assessment Tool), have high sensitivity (86%) and specificity (76%) for identifying aspiration risk in patients with neurological disorders 4, 5
The Volume-Viscosity Swallowing Test (V-VST) is a clinical screening test with 92% sensitivity and 80% specificity for detecting dysphagia in neurological patients 4, 5
The American College of Nutrition recommends the use of FEES (Fiberoptic Endoscopic Evaluation of Swallowing) as an alternative to videofluoroscopy for direct visualization of the swallowing mechanism in patients with neurological disorders 4, 8

Scintigraphy may be useful to assess esophageal transit and evaluate for motility abnormalities or gastroesophageal reflux 1, 6
Computed Tomography (CT) angiography can be considered in hemodynamically stable patients with suspected vascular causes of dysphagia 7

Body Mass Index (BMI) can be used to evaluate for malnutrition, which is present in 0-21% of patients with dysphagia at diagnosis and 7.5-53% during follow-up 5, 9
Weight loss assessment, with weight loss >10% indicative of malnutrition in 21-48% of patients with dysphagia, can be used to evaluate nutritional status 5, 9
Albumin levels can be used to assess nutritional status, particularly in patients being considered for enteral feeding 8

The American College of Radiology recommends that a comprehensive evaluation of both the oropharyngeal and esophageal regions is essential, as dysphagia can be a symptom of both oropharyngeal and esophageal disorders 2, 3
Abnormalities in the mid or distal esophagus can cause referred dysphagia to the pharynx, so the entire esophagus should be evaluated even in patients with apparent oropharyngeal symptoms 2, 6
In patients with neurological disorders, dysphagia may be present even in the absence of symptoms, so objective testing is crucial 4, 9