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Acute Dysphagia in a 60-Year-Old Female with Regurgitation of Food

Diagnostic Algorithm

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Step 1 — Localize the Dysphagia

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Step 2 — Detailed History

Character of Dysphagia

• Solids only → Mechanical obstruction (stricture, ring, neoplasm)
• Solids + liquids from onset → Motility disorder (achalasia, diffuse esophageal spasm)
• Solids then progressing to liquids → Progressive mechanical obstruction (malignancy)
• Intermittent vs. progressive → Intermittent + solid = Schatzki ring; Progressive = malignancy, stricture

Associated Symptoms

• Weight loss + progressive solid dysphagia → Esophageal/gastric carcinoma (red flag)
• Heartburn, acid reflux → Peptic stricture, eosinophilic esophagitis
• Halitosis + gurgling noise + food regurgitated hours later → Zenker's diverticulum (classic in elderly)
• Chest pain → Diffuse esophageal spasm, achalasia
• Odynophagia (painful swallowing) → Infectious esophagitis (candida, HSV), pill esophagitis, malignancy
• Nasal regurgitation, choking, aspiration pneumonia → Oropharyngeal cause
• Neurological symptoms (diplopia, dysarthria) → Bulbar palsy, myasthenia gravis

Relevant History

• Medication history — bisphosphonates, NSAIDs, tetracycline (pill-induced esophagitis)
• History of GERD, Barrett's esophagus
• Prior head/neck surgery, radiation, chemotherapy
• Autoimmune disease (scleroderma → esophageal dysmotility; Sjögren's)
• Smoking, alcohol use (squamous cell carcinoma risk)

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Step 3 — Differential Diagnosis

Oropharyngeal Causes (Structural)

Oropharyngeal Causes (Propulsive/Neurogenic)

Esophageal Causes (Structural)

Esophageal Causes (Motility)

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Step 4 — Physical Examination

• General: Nutritional status, weight loss, pallor (iron deficiency)
• Head & Neck: Lymphadenopathy, thyroid enlargement, neck mass, oral cavity inspection
• Neurological: Cranial nerves (V, VII, IX, X, XII), gag reflex, speech, tongue fasciculations, tremor
• Skin: Telangiectasias, sclerodactyly (scleroderma), Raynaud's
• Abdominal: Epigastric mass, hepatomegaly (metastasis)
• Listen: Gurgling sound in neck on swallowing → Zenker's diverticulum

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Step 5 — Investigations

First-Line

Second-Line (Based on Findings)

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Step 6 — Red Flag Features (Urgent Referral)

• Progressive dysphagia
• Significant weight loss (>5% in 3 months)
• Age >55 with new dysphagia
• Odynophagia
• Hematemesis or melena
• Iron-deficiency anemia
• Persistent vomiting

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Summary Algorithm

Dysphagia + Regurgitation of food
          │
          ▼
  Is it oropharyngeal or esophageal?
          │
   ┌──────┴──────┐
   │             │
Oro-           Esophageal
pharyngeal     │
│              ├─ Structural → OGD (malignancy, stricture, ring)
├─ Structural  ├─ Motility → Manometry (achalasia, DES)
│  → Barium    └─ Extrinsic → CT chest
│    swallow
│    (Zenker's,
│     web, tumor)
│
└─ Propulsive
   → Neurology
     workup
     (MRI, EMG)

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Key Point for This Patient

1. Rule out esophageal/gastric malignancy — urgent OGD with biopsy
2. Zenker's diverticulum — especially if regurgitation is of undigested food, with halitosis or gurgling (Harrison's, p. 1204)
3. Achalasia — if both solids and liquids affected
4. Peptic stricture — if prior GERD history
5. Neurological cause — if oropharyngeal features dominate

Sources: Harrison's Principles of Internal Medicine, 21st Edition, pp. 1204, 1206, 1209

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Updated Approach — New Critical Finding

Clinical Reassessment

The dysphagia and regurgitation in this patient are NOT esophageal or neurological in origin. The lesion on the hard palate is mechanically and reflexively triggering vomiting each time food contacts it.

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The Lesion — Differential Diagnosis

Priority 1 — Oral Mucosal Malignant Melanoma (OMMM) ⚠️

• The hard palate and maxillary alveolus are the most common sites of OMMM
• Typically presents as a black/brown pigmented, raised, irregular lesion
• Can be preceded by a flat melanotic patch (radial growth phase) before becoming nodular/exophytic (vertical growth phase)
• Satellite macules may be present around the main lesion
• Rare but highly aggressive — 5-year survival <20%
• Often asymptomatic until late, which is why dysphagia/regurgitation here is a key presenting complaint

Differential Diagnosis of Black Raised Lesion on Hard Palate

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Immediate Clinical Steps

1. Examine the Lesion Carefully

• Perform diascopy (press glass slide on lesion): vascular lesions blanch, melanoma/melanotic lesions do not

2. Assess the Palate and Oral Cavity Fully

• Look for satellite macules around the main lesion (suggests OMMM spread)
• Inspect entire oral mucosa, gingiva, buccal mucosa
• Palpate for cervical lymphadenopathy (submandibular, jugulodigastric nodes) — indicates regional metastasis

3. Assess Gag Reflex Hypersensitivity

• The lesion, by occupying real estate on the hard palate, may be directly stimulating mechanoreceptors causing an exaggerated palatal reflex
• This is a functional consequence of the lesion, not a primary neurological problem

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Investigations

Urgent

Staging (if melanoma confirmed)

Baseline

• Full blood count, LFTs, LDH (elevated in melanoma = poor prognosis), S-creatinine
• HIV serology (if Kaposi's suspected)

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Management Outline (Pending Histology)

If OMMM Confirmed:

1. Surgery — Wide local excision with clear margins (1–2 cm); may require partial maxillectomy if bone involved
2. Reconstruction — Palatal prosthesis or flap repair
3. Neck dissection — If lymph nodes positive
4. Adjuvant therapy — Radiotherapy (radiosensitive) ± immunotherapy (anti-PD1: pembrolizumab/nivolumab) or targeted therapy (BRAF/MEK inhibitors if BRAF V600E mutated)
5. Multidisciplinary team — Oral maxillofacial surgery, ENT, oncology, prosthodontics

Immediate Symptomatic Relief:

• Soft/liquid diet to avoid contact with lesion and prevent vomiting
• Nutritional support if oral intake compromised
• Topical analgesia if odynophagia develops

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Summary

In this 60-year-old female, the dysphagia and food-contact vomiting are directly attributable to a 5mm raised black lesion on the lateral hard palate triggering an exaggerated palatal reflex. The intact gag reflex excludes neurological disease. The lesion's morphology — black, raised, hard palate location in an elderly female — is highly suspicious for Oral Mucosal Malignant Melanoma until proven otherwise, and warrants urgent incisional biopsy and staging workup.