For example, in a study on the treatment of early prostate cancer, about one-third of the patients received treatment that did not consider their preexisting dysfunctions [ 12 ].
What is dysphagia?
Less than optimal history-taking may also lead to less compliant patients, as evidenced by a report that revealed that poorly communicating doctors have a 1. Suboptimal clinical reasoning during medical history-taking may also result in an incorrect attribution of symptoms or incorrect further diagnostic work-up.
Melleney et al. To competently obtain the clinical history in a problem-solving manner, a thorough knowledge of the causes of each symptom and the symptoms of each disease is mandatory [ 15 ]. Clinically experienced physicians more often use this style of history-taking.
Several authors have stated that medical students typically prefer diagnostic tests and methods for making a diagnosis, whereas experts in the field rely more on the medical history [ 16 ]. Health care professionals of various disciplines provide important input from their individual perspectives for the multidisciplinary management of patients with often complex issues. McCullough et al. There are a small number of published functional health care questionnaires with various limitations that reinforce the importance of further research in this area [ 18 ].
The role of radiologists in taking the history varies greatly, although knowledge of the overall clinical situation is mandatory for an optimal planning, implementation, and interpretation of the radiological study. Therefore, a group of interdisciplinary international swallowing experts participated in a two-step, questionnaire-based process. In such a structured communication process, an expert panel first provides opinions about a key question.
These opinions are then pooled and structured by the researchers and the result is fed back to the expert panel. In the first step, 18 swallowing experts were approached and consented to participate in an interview about their way of taking the medical history. This expert panel consisted of 14 out of 17 members of the original board of the ESSD and 4 invited speakers, attributable to the following medical speciality: eight swallowing experts from otolaryngology departments, four from radiology departments, four members of departments of speech and language pathology, one from an internal medicine department, and one from a department of surgery.
The experts reported that they saw about patients per year, on average, ranging from to For step 1, an interview manual with 14 items was designed to serve as a guiding tool for the open-ended interviews Appendix 1. For step 2, the themes and their respective questions covered during history-taking in patients with swallowing problems, as identified in step 1, were listed. In addition, the experts were asked to indicate whether they approved of the given structure of the questions and whether they could imagine using a questionnaire based on this structure for their future work.
For the first step, swallowing experts were interviewed by an experienced radiologist P. Notes, taken immediately during the interview, were transcribed and subsequently mailed to each swallowing expert for review and specification. Swallowing experts were emailed the results of step 1 and invited to participate in a questionnaire where they rated the importance of each question. Frequencies within each coding dimension and each subcategory were counted. The percentage of the expert sample that provided items for each subcategory was also determined. Step 2: To determine the importance of each question given in step 1, the scores of each rating of the questionnaire were averaged over the total number of experts to evaluate the average predictive value.
The results were entered in a spreadsheet application and were expressed as percentages of the responses. The 18 experts provided 25 different items, categorized as general questions. Step-2—Rating the importance of themes and questions during medical history-taking in patients with swallowing disorders. Numbers indicate the average expert estimated value assigned by the swallowing experts of the second assessment round. Numbers indicate the average predictive value assigned by the swallowing experts of the second assessment round.
In addition, the experts added important questions that were missing after the first interview round. Each of the 18 interviewees stated that they documented the history of the patient. Nine of 18 reported using at least one standardized questionnaire about swallowing problems in their clinical routine Dysphagia handicap index, EAT 10, Mini nutritional assessment, SWAL-QOL, Sydney swallow questionnaire, and locally developed questionnaires.
All in all, 10 different questionnaires were mentioned. The goal of this study was to obtain a range of answers from a widespread, diverse group of experts from different disciplines about how to take a medical history in patients with swallowing disorders. Previously, various studies have revealed the relevance of the medical history for making a final diagnosis and showed a high agreement between the diagnosis made after taking the history and reading the referral letter and the final diagnosis [ 8 , 9 ].
In a study from , Graber et al. Clinical evaluation of swallowing is a subjective evaluation to identify possible causes of deglutition disorders, evaluate the risk of aspiration, and decide on further diagnostic tests.
Dysphagia : Diagnosis and Treatment
The role of different swallowing disorders in determining the various causes of dysphagia still remains a challenge. However, these subjective experiences can be narrated, and selected symptoms and clinically easily assessable variables can help to discriminate different causes of dysphagia [ 26 ]. Particularly in the work-up of this patient group, skilled history-taking may lead to differences in planning the diagnostic procedure and in guiding further diagnostic testing. In addition, the speed of onset and mode of progression of specific symptoms may not be helpful in predicting certain diseases.
For example, patients with dysphagia associated with benign disease often report weight loss, which may be misleading [ 14 ]. For this reason, a general questionnaire that covers a wide range of issues may help to detect patients with swallowing problems that would likely go undetected if diagnosis relied solely on self-reporting. Another issue is the request to involve the patient in the decision-making process and further diagnostic steps.
Patients want an effective dialogue with their physician and authentic caring in their clinical relationship [ 27 — 29 ]. This is reflected by the fact that the majority of experts stated that the ability to establish a therapeutic relationship, as well as an understanding of the patient, and the involvement of the patient and his accompanying persons, were the critical factors for a successful patient—physician communication. Fast-track investigation of dysphagia has a low success rate in diagnosing esophageal disease, and specialized physicians may facilitate an early diagnosis [ 14 ].
General guidelines may be considered too generic to be applied to specific situations. Effective communication differs from situation to situation, reinforcing the need to tailor the communication to the specific situation of each consultation. It has been suggested that specific guidelines be developed for the approach to specific diseases [ 30 ].
The advantages of questionnaires include the fact that they are easy to use, do not require a lot of effort compared to the information the physician obtains from the patient, and may be an important tool for evaluating problems and guiding further treatment decisions.
Questionnaires for characterizing swallowing disorders vary largely among different institutions, and a review of the literature revealed many different screening tools [ 31 ]. This was also seen in our interviews, where nine of 18 interviewed experts indicated the use of at least 10 different questionnaires.
Articles that cover tools to identify patients with dysphagia began to be published in [ 32 ]. The increasing number of publications may be explained by the growing presence of speech-language pathologists in the healthcare setting and the progressive concern for the early detection of dysphagia to ensure a safe diet and prevent respiratory and nutritional complications. Most questionnaires cover the oral and pharyngeal symptoms, including items to evaluate aspiration and oropharyngeal dysphagia. This may be due to the fact that several of the swallowing experts interviewed were specialists in oropharyngeal dysphagia.
The intent of this study was to present a collection of questions by experts covering all aspects of the upper gastrointestinal tract. Radiologists will have contact with patients who have swallowing disorders during their training and career, and could benefit from structured guidance for a comprehensive interview.
Determining the correct questions in a clear and simple way during the encounter, to ensure that the patient understands was one of the most important factors named when the experts were asked for examples of successful patient—physician communication. Therefore, a collection of questions that help to explore the diverse symptoms of swallowing disorders comprehensively may serve as an aid for radiologists of all training levels. A better understanding of the causes of swallowing problems, which could be achieved by asking the right questions, helps to customize the investigation of the individual patient, a prerequisite for a correct diagnosis.
However, in times of the growing importance and awareness of a value-based imaging care, swallowing studies as safe, non-invasive, and cost-effective diagnostic tests will be appreciated. Controversely, in a busy radiological department time restraints may prohibit a detailed history-taking of all patients, also shown in our study, in which seven experts stated enough time as a significant factor for successful patient—physician communication. The role of the radiologist in this setting is varying in different countries and institutions, ranging from sole responsibility in performing the patient communication and investigation to a more supportive role alongside speech therapists.
Patients may also present for the first time in a radiological department without known aspiration and unspecific symptoms. One limitation of this study is that the respondents of the first interview round were not completely identical with the experts of the second survey. Nevertheless, all experts of the second study round were dedicated experts in examining patients with swallowing disorders, with comparable clinical experience and working together with specialists in interdisciplinary deglutology centers.
Although the number of experts is not very high, the topic of a comprehensive history-taking is important, and the presented collection of questions may serve as an aid in taking the history in this selected patient group. Another limitation is the fact that asking these questions is only suitable for patients who are not limited by neurological factors and are able to understand the content of the questions.
Dysphagia: Symptoms, diagnosis, and treatment
Further research is required for consensual creation and validation of a multidisciplinary questionnaire for patients with swallowing disorders. Usually caused by nerve or muscle problems, dysphagia can be painful and is more common in older people and babies. Although the medical term "dysphagia" is often regarded as a symptom or sign, it is sometimes used to describe a condition in its own right. There is a wide range of potential causes of dysphagia; if it only happens once or twice, there is probably no serious underlying problem, but, if it occurs regularly, it should be checked out by a doctor.
Because there are many reasons why dysphagia can occur, treatment depends on the underlying cause. In this article, we will discuss the various causes of dysphagia along with symptoms, diagnosis, and potential treatments. A typical "swallow" involves several different muscles and nerves; it is a surprisingly complex process. Dysphagia can be caused by a difficulty anywhere in the swallowing process. There are three general types of dysphagia:. Oral dysphagia high dysphagia — the problem is in the mouth, sometimes caused by tongue weakness after a stroke , difficulty chewing food, or problems transporting food from the mouth.
Pharyngeal dysphagia — the problem is in the throat.
Issues in the throat are often caused by a neurological problem that affects the nerves such as Parkinson's disease , stroke, or amyotrophic lateral sclerosis. Esophageal dysphagia low dysphagia — the problem is in the esophagus. This is usually because of a blockage or irritation. Often, a surgical procedure is required.
It is worth noting that pain when swallowing odynophagia is different from dysphagia, but it is possible to have both at the same time. And, globus is the sensation of something being stuck in the throat. Possible causes of dysphagia include:. Amyotrophic lateral sclerosis — an incurable form of progressive neurodegeneration; over time, the nerves in the spine and brain progressively lose function.