A case of occult oropharyngeal dysphagia.

To the Editor: Requests for feeding tube placement, in those newly diagnosed with dysphagia, is a common request of the gastrointestinal medicine service. Most dysphagia is either oropharyngeal or esophageal. The prevalence of oropharyngeal dysphagia is very high in patients with neurologic diseases such as cerebral vascular accidents (CVA), Parkinson disease, and amyotrophic lateral sclerosis (AML), as well as in more than 60% of elderly institutionalized patients. (1,2) We describe the case of an adult patient with severe mental retardation who developed substantial oropharyngeal dysphagia and aspiration pneumonia after an unknown foreign body ingestion.

A 43-year-old mentally retarded white male resident of a state mental institution was transferred to our Emergency Department (ED) due to new onset fever and dyspnea. His nurse reported a two-day history of nonproductive cough and no history of pneumonia. The patient was nonverbal secondary to severe intellectual disability and presented with increased oral secretions that were suctioned in the ED.

On physical examination, blood pressure was 106/75 mm Hg; pulse 111; respirations 26/min; oxygen saturation 92% on room air; and temperature 38.9[degrees]C. The examination was normal except for tachycardia and bibasilar rhonchi. Perioral and peripheral cyanosis was absent. In the ED, a CT was done to exclude a Pulmonary Embolus and Deep Vein Thrombosis, but did show right lower lobe pneumonia. Labs were significant for WBC of 14,300 with 65% neutrophils, 3% bands, and 21% lymphocytes.

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The patient was admitted, diagnosed with aspiration pneumonia, and placed on antibiotics. After 24 hours, the patient was without fever or leukocytosis. Due to suspected aspiration, a bedside swallow evaluation was performed which was significant for impaired swallowing. Modified Barium Swallow Study revealed severe aspiration. Speech pathology recommended an alternate feeding route due to high risk of aspiration.

GI Medicine was consulted for percutaneous endoscopic gastrostomy (PEG) tube placement. EGD was performed before anticipated PEG placement. The endoscope was passed without difficulty to the hypopharynx. A foreign body was discovered at the hypopharynx and removed by rat tooth forceps. The foreign body was identified as a chicken bone (Fig.). After removal of the chicken bone, reevaluation by speech pathology demonstrated minimal aspiration risk. The patient was discharged in stable condition with a recommendation for a soft mechanical diet. One month after hospital discharge, patient was eating his regular diet without any further episodes of aspiration pneumonia. Clinicians should carry a high suspicion for foreign body ingestion in mentally disabled patients who are unable to give a history and present with acute onset dysphagia, sialorrhea, regurgitation, and unexplained respiratory symptoms. (3)

Raymond Bedgood, DO

Melvin Bullock, MS IV

Ayaz Chaudhary, MD

Medical College of Georgia 

Augusta, GA

References

1. Clave P, Terre R, de Kraa M, et al. Approaching oropharyngeal dysphagia. Rev Esp Enferm Dig 2004;96:119-131.

2. Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology 1999;116:455-478.

3. Dallal HJ, Odum J, Ahluwalia NK. Covert dysphagia in the mentally handicapped: two case reports and a review of the published literature. Dysphagia 1996;11:194-197.

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