In previous issues of HAUSARZT PRAXIS, a broad spectrum of possible causes of dysphagia has been presented in this section, and case studies have been used to explore these in greater depth. As can be seen from the workup of a single patient in chronological progression described in this article, interdisciplinary collaboration and patience are essential, especially in complex cases.
Alterations and diseases with a neurological, orthopedic, internal medicine, and oncology background were presented and the importance of the different imaging modalities was assigned. The case presented today shows in the course of several years in a patient who is now 61 years old that dysphagia can also have a multicausal background, challenging different medical specialties and requiring different diagnostic procedures including imaging.
Case study
The case case history demonstrates the complexity of dysphagia over an eight-year course in a patient 53 years old at the time of first contact in our practice, whichled her to consultations with family practice internist, surgery, ENT, neurology and orthopedics. This resulted in various imaging studies, which are discussed below in chronological order.
June 2014
The 53-year-old patient is in a good general condition. There is thyroid medication with Eferox 25, 1 tablet daily. She describes alternating episodes of agitation and fatigue, also a feeling of pressure and lumpiness in the throat. The primary care internist requested an evaluation of the thyroid situation. Laboratory chemistry showed FT4 and FT3 in the normal range, TSH basally decreased. Sonography and thyroid scintigraphy (72 MBq 99 Tc-pertechnetate) demonstrated a struma nodosa with focal autonomy extending to the retrosternal region and markedly emphasized on the left side (Figs. 1A and 1B). Thesonographically recognizable nodular structures in the right thyroid lobe with depression of activity uptake were less developed. Definitive thyroid rehabilitation with thyroidectomy was performed as a result of the nuclear medicine examinations recommended.
November 2015
With slowly increasing pressure and a feeling of lumpiness in the throat and the onset of dysphagia, the patient consulted a ENT physician colleagues. Anesophageal x-ray was requested to rule out a passage obstruction. The porridge swallow with barium sulfate (Figs. 2A and 2B) attested normal mucosal conditions of the esophagus and unobstructed passage. A diverticulum, tumorous process or even external mechanical alteration could be excluded. The cervical spine with minor degenerative changes showed an extensor malposition with resulting possible myogelosis.
2017
The patient could only decide to undergo surgical intervention with total thyroid surgery 3 years after the diagnosis was made. The initial symptoms were progressive with increasing dysphagia and also hyperthyroid metabolic situation.
July 2020
With persistent postoperative dysphagia, the patient again sought the ENT physician on. The latter could not detect any change relevant to the symptomatology, a neurological consultation also did not reveal any pathological findings. Finally, an MRI of the neck was performed (Fig. 3A and 3B) to exclude pathologic change. The soft tissue findings of the neck were unremarkable, pathological changes of the soft tissue structures could be excluded. After strumectomy, there was no thyroid tissue left or excessive scarring.
March 2022
In the further course a presentation in an orthopedic practice took place. The clinical situation indicated a cervical spine syndrome. For clarification, an MRI of the cervical spine was performed (Fig. 4A and 4B). This confirmed the cervical spine statics known from the X-ray examination in 2015; a herniated disc or cervical myelopathy with slight bulging of the C5/6 disc with initial osteochondrosis of the C4/5/6 segments could be ruled out.
In summary, the cause of persistent dysphagia has not been clearly established. Inflammatory or space-occupying changes of the soft tissues of the neck could be excluded. The misstatics of the cervical spine as a cause of the permanently existing symptoms seems possible, as well as psychogenic influences.
Take-Home Messages
- Dysphagia is a symptom, not a disease.
- The possible causes are manifold.
- In many cases, intensive interdisciplinary cooperation between different specialties of human medicine is required.
- The diagnostic spectrum includes exact anamnesis, clinical and laboratory chemical examination, supplemented by imaging examination procedures.
- If symptoms persist and morphological organ changes are excluded, functional or psychological causes must also be considered.
Further reading:
- See references in previous articles in the Images series on dysphagia: Hausarzt Praxis 3/2022-09/2022; also available at www.medizinonline.ch.
- Arens C, Hermann F, Rohrbach S, et al: Position paper of the DGHNO and the DGPP – Status of clinical and endoscopic diagnosis, evaluation and therapy of dysphagia in children and adults. Laryngorhinootology 2015; 94(S 01): S306-S354.
- Thiel MM, Ewerbeck C (eds.): Praxiswissen. Dysphagia. Diagnostics and therapy. Springer-Verlag: Berlin, Heidelberg, New York; 2010.
HAUSARZT PRAXIS 2022; 17(10): 62-64
