Objective: To highlight the risks of investigation of patients with swallowing disorders by "barium swallow", when the disorders may arise from dysfunction of the upper swallowing tract.
Clinical features: An 81-year-old Italian woman presented to her local doctor with a history of dysphagia of five days' duration. A barium swallow resulted in aspiration of a large amount of barium into the right main bronchus, causing severe problems. After a period of intensive respiratory care including intubation and continuous positive airway pressure, she recovered sufficiently to be referred to a rehabilitation unit. She had mild hemiplegia but severe dysphagia, secondary to a brain stem infarct.
Intervention and outcome: Persisting severe dysphagia was confirmed, with extreme risk of aspiration. The patient underwent percutaneous endoscopic gastrostomy and was discharged to live independently, but requiring long-term gastrostomy feeding.
Conclusion: When a patient presents with dysphagia, great care should be taken to exclude upper tract dysfunction with its attendant risk of aspiration, generally by referral to a centre or consultant with expertise in this area, before ordering or carrying out investigations appropriate to disorders of the lower tract.