Pediatric emergency medicine trisk 1106 1106
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an acute onset of dysphagia generally requires a more urgent approach. Witnessed
or suspected foreign bodies, either ingested or aspirated, should be investigated
with plain radiographs (or contrast studies if a radiolucent object is considered)
and, emergently removed as indicated (see Chapter 32 Foreign Body: Ingestion
and Aspiration ). A history of neck trauma or caustic ingestion should lead to
concern for aerodigestive tract abnormalities. These patients may present
dramatically with neck pain, drooling, and evidence of facial or other trauma, but
they may also have a subacute presentation (see Chapters 102 Toxicologic
Emergencies , 106 ENT Trauma , and 112 Neck Trauma ). Presence of fever or
signs of systemic illness may result from potentially life-threatening infectious or
inflammatory conditions ( Table 56.3 ). Less severe problems (gingivostomatitis
or thrush) may present with mouth lesions and can be managed on an outpatient
basis after careful assessment of hydration status. Severe problems, including
Stevens–Johnson syndrome, herpetic esophagitis, and diphtheria, may be
discovered on examination and likely will require inpatient management.
Patients with a nonacute history of swallowing difficulty can be evaluated and
managed as shown in Figure 56.2 . The initial emphasis with these patients lies
more in determination of nutritional status and development issues than in acute
emergency department intervention, although prolonged feeding difficulty can
develop into a life-threatening problem. Evaluation of these patients often
involves a multidisciplinary approach. The child with obvious anatomic
abnormalities, neurologic impairment, specific syndromes, or a tracheostomy
may need referral to appropriate subspecialists after initial evaluation. The child
without obvious anatomic or neurologic abnormality who has weight loss or
failure to thrive may be evaluated as an outpatient.
Radiographic evaluation of the stable dysphagic patient usually begins with an
examination of the airway and soft tissues of the neck, looking for evidence of a
foreign body, mass, airway impingement, or other abnormality. A chest
radiograph may suggest aspiration pneumonia, congenital heart disease, or
mediastinal abnormality or, as in the patient with achalasia, demonstrate fluid
levels within an enlarged esophagus. Helical computed tomography scan,
echocardiography, or angiography may further identify problems suspected from
initial studies.
A videofluoroscopic swallowing study (VFSS or modified barium swallow
[BS]) is currently the gold standard for evaluating pre-esophageal disorders. This
dynamic study may reveal evidence of aspiration, nasopharyngeal reflux, motility
disorders, obstructions, masses, cricopharyngeal dysfunction, fistulas,
inflammatory processes, or other causes of dysphagia. VFSS differs from the
