Pediatric emergency medicine trisk 1101 1101
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abnormality of the trachea, esophagus, or larynx. Congenital vascular lesions
causing extrinsic compression of the esophagus may remain silent until the
introduction of solid food, or may rarely manifest as dysphagia later in adulthood.
Gastroesophageal reflux in infants may manifest as vomiting shortly after feeding
or with a history of nighttime cough or emesis. Intrinsic lesions, from
inflammation, tumor, or foreign body, may create problems with solid food but
cause no difficulty with liquids. Infants with previously unrecognized
neuromuscular disorders commonly present initially with dysphagia, particularly
for liquids, drooling, prolonged feeding time, weak suckle, or nasal reflux of
swallowed material. A history of fever may indicate aspiration pneumonia or
other infectious or inflammatory causes of dysphagia. Determining whether
symptoms are progressive or intermittent/nonprogressive can also be helpful.
The child with dysphagia should undergo a thorough general physical
examination, initially focusing on the patient’s cardiopulmonary status. Evidence
of respiratory distress or cardiovascular compromise should be treated promptly
in the appropriate manner, as outlined elsewhere in this text (see Chapters 8
Airway and 9 Cardiopulmonary Resuscitation ). Assurance of a secure and stable
airway should precede attempts to examine the oropharynx or to remove a foreign
body (see Chapter 32 Foreign Body: Ingestion and Aspiration ).
In the stable dysphagic patient, evaluation of head size and shape, facial
structure, mandibular development, tongue disproportion, and ear configuration
may provide evidence of an underlying congenital abnormality, such as Pierre
Robin, Treacher Collins, Crouzon, and Goldenhar syndromes. Evaluation of nasal
airway patency in the infant can be determined by gently passing an 8F catheter
through the nares into the stomach. If the catheter fails to pass easily, choanal
stenosis, atresia, or esophageal obstruction must be considered. Inspection of the
oral cavity, pharynx, and neck may reveal a cyst, mass, localized infection, or
inflammatory cause for dysphagia. Cervical auscultation over the thyroid
cartilage during feeding may note evidence of aspiration if upper airway breath
sounds are abnormal or if the timing of breathing and swallowing is
uncoordinated. The pulmonary examination may also detect signs of aspiration or
respiratory compromise, including elevated respiratory rate, increased respiratory
effort, stridor, stertor, rales, rhonchi, wheezing, or change in voice quality.
Neurologic examination may reveal an altered level of arousal from an
underlying brain injury or depressed sensorium from drugs or infection that may
limit effective swallowing. Examination of the cranial nerves, particularly V, VII,
IX, X, and XII, may reveal abnormalities from traumatic or surgical injury, tumor,
or congenital disorder. Evaluation of muscle tone, strength, and reflexes in
