“Ken” is a 58-year-old construction worker who appears to be in perfect health. He only has one concern—he has trouble swallowing his large vitamin pills. This hasn’t always been a problem for Ken; in fact, it only started about six months ago. During a routine check-up, Ken mentioned this issue to his primary care provider, who provided him with a referral to a speech-language pathologist.
Identifying the Source of Ken’s Dysphagia
During Ken’s intake, his SLP noted that Ken wasn’t having problems with any other bolus. He had also not lost any weight. Still, the SLP was concerned. Dysphagia is never normal, even a seemingly benign dysphagia like no longer being able to swallow large pills. So Ken’s SLP ordered a modified barium swallow study in the anterior-posterior projection.
You can view Ken’s results below.
The swallow study revealed an obvious abnormality of bolus flow localized to either the hypopharynx or the cervical esophagus with considerable residue in the right piriform sinus with no visualized aspiration. It wasn’t clear to Ken’s SLP where the obvious bulging was, so he referred Ken for fiberoptic endoscopy to rule out a hypopharyngeal source. A good examination using this technique should not only include visualization of pharyngeal and laryngeal structure, but also an evaluation of their physiologic performance. This should include use of the Valsalva maneuver (forced breath hold) to look at pharyngeal and laryngeal competence under stress.
You can see the results of this study below.
Ken’s SLP reviewed the results of the study. As Ken performed the Valsava maneuver, a large lesion became visible, arising from the left piriform sinus from the cervical esophagus, eventually covering the airway with increased effort. The lesion was consistent with a giant fibrovascular esophageal polyp.
Ken’s SLP referred him for surgery to have the polyp excised. The surgery solved the problem and relieved Ken’s symptoms.
An inability to swallow large pills seems like such a minor thing. It would have been easy for either Ken’s primary care provider or his SLP to dismiss it and just tell him to look for smaller pills or offer techniques that would facilitate swallowing the pills, such as grinding them up into applesauce. Fortunately, both the PCP and the SLP noted that this was a change for Ken, which alerted them to the fact that something was wrong.
This specific complaint of dysphagia on only one item turned out to be a rare and unsuspected lesion that was managed surgically with success. Without treatment, this polyp would have continued to grow, and Ken likely would have developed more severe dysphagia, weight loss, respiratory symptoms, and even regurgitation that could lead to aspiration and asphyxia. Prompt action by Ken’s PCP and his SLP may have avoided any medical complications.