Episode 6: Dysphagia
Author: Dr. Suneet Sood
Editor: Dr Suneet Sood
Narrators: Thong Yi Kun, Alan Koay
So, what case do you have today?
I have this case of a common symptom presenting from an uncommon condition, which highlights the importance of taking a proper history, examining well, and keeping an open mind.
So tell us.
Well, this 64 year old gentleman, diabetic, hypertensive, presented to the emergency department with dysphagia. Dysphagia means surgical referral; surgical referral for dysphagia means upper gastrointestinal endoscopy.
It sounds reasonable. What did the scope show?
Nothing! In fact, a senior surgeon came along and repeated the scope. Still nothing!
That’s funny, but if I remember right, dysphagia due to early achalasia may easily be missed by endoscopy.
True, but wait for the complete history, which was taken some days later by a smart undergraduate student, even as the symptoms were improving. The patient had dysphagia for only five days. Careful examination showed hoarseness, along with reduced sensation on the right face, right upper limb, and right lower limb. The left ninth, tenth, and twelfth nerves were also affected. He had an unsteady gait, but there was no limb weakness. The student looked up the books and came up with a diagnosis of Wallenberg’s syndrome, also known as the lateral medullary syndrome. She kept a CNS tumour as a differential.
What’s Wallenberg’s syndrome?
Wallenberg’s syndrome is a lower brainstem lesion that results from an occlusion of the vertebral artery. The patient develops sensory deficits of the face on the same side as the infarct, and sensory deficits of the trunk and extremities on the opposite side. Other typical features include dysphagia, dysarthria, hoarseness, and ipsilateral cerebellar signs–that means that patient falls to side of lesion. An MRI is diagnostic.
What did the neurologist say?
The neurologist confirmed the Wallenberg’s syndrome. He said that the ipsilateral features of ataxia were due to damage to the inferior cerebellar peduncle and cerebellum, while the contralateral features of loss of pain and temperature sense in the body and extremities indicated involvement of the anterior spinothalamic tract. The prognosis is good, and, in fact, the patient had already recovered largely within a couple of weeks. The neurologist also commented that acute neurological symptoms are caused by vascular or demyelinating disorders, almost never by tumours. And the MRI was consistent.
What’s your message to our listeners?
As always, take a good history. Examine carefully. And, I think, the main message is “not all dysphagia arises from the esophagus”.
Saha DK, Saha M, Nazneen S. Lateral Medullary Syndrome. Bangladesh Critical Care Journal. 2017;5(1):72-3.