Swallowing and oropharyngeal dysphagia

Editor – We read the article by O’Rourke and colleagues (Clin Med April 2014 pp 196–9) with great interest, but were puzzled by the absence of any reference to neurological examination. It is our experience that, in the initial stages of the diagnostic process, a primary neurological cause for oropharyngeal dysphagia is rarely considered by general practitioners (GPs) or by ear, nose and throat (ENT) specialists. We suggest that, in cases where bedside assessment has not revealed an obvious cause, an opinion from a neurologist might usefully precede the initiation of videofluoroscopy and other investigations.

A study of patients seen in our tertiary referral clinic with bulbar-onset motor neurone disease (MND) revealed that at least 50% were initially referred to non-neurological services, frequently to the transient ischaemic attack (TIA) clinic, despite a clear history of progressive symptoms in the vast majority of cases.¹ The other major erroneous referral pathway was via the ENT clinic, where ‘satisfactory’ direct laryngoscopy had been reported. In some cases the combination of dysphagia and weight loss, common in MND with significant bulbar involvement, had resulted in multiple unnecessary oesophagogastroduodenoscopy procedures, delaying the placement of a palliative gastrostomy. Within the realm of neurology there are also valuable clinical observations – in particular that dysarthria invariably precedes dysphagia in progressive neurodegenerative causes of bulbar dysfunction. Conversely, a structural cause must be considered in cases of dysphagia without dysarthria.²

We believe the assessment of dysphagia to be an area of medical education that deserves a dedicated, problem-based approach that cuts across neurology as well as otolaryngology and gastroenterology. There are important ramifications for delayed diagnosis and management, particularly of neurodegenerative conditions, which will become more prevalent with an ageing population.