Dysphagia in Outpatient Practice: Workup

How to identify in clinic

• Ask: "Do you ever cough or choke when eating or drinking?"
• "Do you feel food getting stuck?" "Have you lost weight?"
• EAT-10 — validated 10-item dysphagia screening
• 3-oz water swallow test — observe for coughing, wet voice
• Observe at meal if possible — pocketing food, slow eating, avoidance

Red flags for aspiration

• Recurrent pneumonia — especially right lower lobe
• Wet/gurgly voice after swallowing
• Weight loss with reduced oral intake
• Silent aspiration — no cough reflex, common in stroke and dementia
• Fever of unknown source in a patient with known dysphagia

Common causes

• Stroke (most common neurogenic cause)
• Dementia (late-stage)
• Parkinson's disease
• Medications causing dry mouth
• GERD / esophageal stricture
• Head/neck cancer

Non-pharmacologic (primary approach)

• Speech-language pathology (SLP) evaluation — the essential referral
• Diet texture modification per SLP recommendation (IDDSI framework)
• Thickened liquids if thin liquid aspiration confirmed
• Compensatory strategies: chin tuck, small bites, upright positioning
• Oral hygiene — reduces bacterial load and aspiration pneumonia risk
• Supervised meals for high-risk patients

Medications

• Treat GERD if contributing (PPI)
• Manage dry mouth — saliva substitutes, review anticholinergics
• No medication treats dysphagia directly

Avoid

• Assuming coughing during meals is "normal aging"
• Prescribing diet changes without SLP assessment
• Ignoring silent aspiration — it's the most dangerous form

When to refer

• SLP — any suspected dysphagia (clinical swallow eval, VFSS, FEES)
• GI — if structural cause suspected (stricture, mass, achalasia)
• ENT — if laryngeal pathology or head/neck mass
• Palliative care — if progressive dysphagia in advanced illness

Documentation must include

• Screening performed and result
• Aspiration risk assessment
• Diet recommendations
• SLP referral and timing
• Goals of care context if advanced illness