(P05) A Case of Rapid and Unexpected Esophageal Dysmotility

Introduction: Swallowing is an important yet complex function that is affected by normal aging as well as processes of structural, neurological, or infectious etiologies. Dysphagia can affect any level of swallowing (oropharyngeal or esophageal) and early recognition and management are important for the nutrition, safety and overall care of the older adult in post-acute care and long term care (PALTC) setting.

Case Description: A medically complex 97-year-old underwent orthopedic repair of a femur fracture with subsequent post-acute care admission. She subsequently developed new-onset dysphagia of solids and liquids. Prior to this incident, she was eating foods of all consistencies. Esophagogastroduodenoscopy revealed a significantly tortuous esophagus with changes consistent with mild esophagitis dissecans and retained food bolus in the distal esophagus. The team viewed no clear strictures. In the setting of persistent symptoms, speech performed a fluoroscopic video swallow which showed no oropharyngeal dysphagia. Radiology performed an esophagram which revealed severe esophageal dysmotility and absent peristalsis. The medical team placed a temporary nasal-jejunal tube, which was removed during her rehabilitation at the PALTC facility upon her toleration of a soft oral diet. With close follow-up, she continued to maintain caloric and protein intake with stable weights and minimal gastrointestinal side effects throughout her rehabilitation and transition to long-term care.

Discussion: Our patient was suspected to have dysphagia secondary to general anesthesia during her recent orthopedic procedure. Incidence of post-extubation dysphagia varies, with an incidence as high as 62%. Age increases this incidence by 5-fold as dysmotility, or presbyesophagus, predisposes older adults to dysphagia. Post-extubation dysphagia is an independent predictor of 28- and 90-day mortality. PALTC providers should be aware of the signs and symptoms including choking, coughing, drooling, difficulty swallowing, and change in vocal quality. These symptoms are usually noted within 48 hours of extubation and warrant prompt evaluation. The etiology can be related to direct laryngeal trauma, inflammation, occult neurologic injury leading to altered sensation, neuromuscular weakness, or dyssynchronous breathing and swallowing, operative complexity and duration of intubation, advanced age, and frailty. PALTC providers should consider other etiologies of dysphagia including oropharyngeal dysphagia or esophageal dysphagia. In our case the rapid onset following surgery were clues to the etiology of dysphagia from intubation. This case highlights the importance of interdisciplinary efforts for early identification of older adults with dysphagia in the PALTC setting.