More questions about dysphagia...

Hello Dr. Kevin,

Thanks for your answers to my earlier post regarding my sudden onset of oropharyngeal dysphagia.

I have had a laryngoscopy (indirect and direct transnasal) by my ENT who said there were no obstructions, masses or irregularities in my throat. I saw him a second time (after 6 weeks of symptoms, sensation of pharyngeal residue when eating, particularly on right side). He said it was possibly a manifestation of GERD and put me on Prevacid 3 days ago (with no difference noticeable yet).

My GI recommended a Barium Swallow two weeks ago, which I did today. The doctor performing the Videofluoroscopic procedure said no structural abnormalities or obstructions were noted. It was a full top to bottom esophagram.

He did, however, note two things: a) that there is some 'pooling' in my lower pharynx that is not obstruction related - it is just appearing to take 'extra swallows' to clear. Second, he noted considerabl reflux, which would be consistent with the ENTs guess.

My questions are:

1) could my oropharyngeal dysphagia be a symptom of GERD in the absence of structural abnormalities? I have occasional hoarseness too, but the ENT saw no laryngeal irritation. I believe I have read that GERD can affect the Upper Esophageal Sphincter?

2) how effective is Prevacid? How long should it take before improvement might be seen, and if it works will I have to stay on it for life? Are their medications other than Prevacid that are better, or in case Prevacid doesn't work for me?

3) My GI said originally that if the Barium Swallow came up with nothing, then he might suggest an upper endoscopy. In the absence of structural abnormalities, is there value in this procedure? (He will not receive the Barium Swallow results for another week or so). If reflux appear to be the issue, wouldn't trying PPIs for a while be a good strategy, or maybe a pH test? Or would he want to take a look around inside to see if there is any damage from the reflux?

5) Could there be anything other than GERD causing the dysphagia sensation? Stress for instance? (my wife became pregnant with multiples around the time I started having these difficulties). I know there are some neurological conditions that could be the cause, but I have no other symptoms anywhere. My annual physical just came back normal across all panels: lipid, metabolic and blood.

As always, thank you in advance for your kind attention.

[Kevin Pho, MD]

1) In the absence of any anatomical abnormalities, GERD is certainly a plausible possibility.  A 24-hr pH study would be the definitive test to evaluate this.  

2) Prevacid is a good medication.  It is in the class of proton pump inhibitors (PPIs) - if GERD is present, the effect should be pretty rapid.  Note that a similar medication known as prilosec is going over the counter soon.  Typically you will stay on it for a few months, and then you will be re-assessed as to whether you will continue to need this.  

3) An upper endoscopy would definitely be worth it.  It is a more comprehensive test than the barium swallow.  If the upper endoscopy is negative, then I would consider the 24-hr pH test.  

4) Given the fact you have had many tests - it would be unclear.  The upper endoscopy combined with the ENT evaluation is a very comprehensive evaluation for dysphagia.   I would work on controlling the reflux and re-assessing the dysphagia after then.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.