What is a typical first-line assessment when dysphagia is suspected?

• A. Endoscopy
• B. History and bedside swallow examination
• C. Manometry
• D. Barium swallow

Answer: (B)

When dysphagia is suspected, the first step is to obtain a thorough history and perform a bedside swallow examination. The history quickly highlights risk factors and red flags—onset and progression, whether problems occur with solids, liquids, or both, coughing or choking during meals, regurgitation, weight loss, prior stroke or neurologic disease, and medications—that help gauge the likelihood of aspiration and the overall safety of swallowing. The bedside evaluation then lets you observe how the patient manages saliva and food in real time: oral prep and transit, bolus control, the ability to propel the bolus, airway protection during swallowing, and the presence of any coughing, voice change, or wet voice after swallows. This combination helps determine if the swallow appears safe or if there’s a high risk of aspiration, guiding the need for further instrumental testing.

Endoscopy or videofluoroscopic tests are more invasive or resource-intensive and examine anatomy, airway protection, and swallow mechanics in ways the bedside exam cannot alone capture. They’re typically pursued after screening when clearer or more detailed information is needed. Manometry assesses esophageal pressures and motility, which is a different issue than initial oropharyngeal swallowing safety. A barium swallow evaluates swallow mechanics and esophageal transit but is usually reserved for cases where structural or esophageal problems are suspected or when prior bedside findings warrant detailed imaging.