Original Article: Dysphagia: Evaluation and Collaborative Management
Issue Date: January 15, 2021
See additional reader comment at:https://www.aafp.org/afp/2021/0115/p97.html
To the Editor: Strangulation is an important cause of dysphagia and is relevant to family physicians. Strangulation involves applying pressure to the neck with the hands, a constricting band, or an arm. It can diminish cerebral blood flow or occlude the airway and result in carotid artery dissection, making it a potentially lethal act.1 Strangulation is commonly associated with intimate partner violence (IPV), and women are at particularly high risk, with a documented sevenfold increased risk of death from homicide among women experiencing IPV-related strangulation.2
Survivors of strangulation report that when they sought medical attention, symptoms such as difficulty swallowing were often dismissed or incorrectly attributed to more common ailments. Because physicians cannot rely solely on visible findings to identify strangulation, dysphagia is an important presenting symptom. In addition to dysphagia, patients commonly experience neck pain, sore throat, voice changes, and neurologic manifestations.3
Physicians with a high index of suspicion for strangulation should screen patients appropriately. Survivors may not disclose their experience because of impaired memory, lack of knowledge regarding the seriousness and sequelae of strangulation, or unfamiliarity with the term strangulation.4 Questions about strangulation should include terms more familiar to survivors, such as choked, blacked out, jacked-up, or choked-off.5 Inquiry should also be made about a loss of consciousness.
Management varies based on the time of presentation and may involve additional imaging, including imaging of the carotid artery.4 Recognizing dysphagia as a symptom of strangulation may also prevent unnecessary interventions, such as prescription of a proton pump inhibitor or invasive procedures.
In Reply: We appreciate the thoughtful comments of Drs. Giusti and Ravi and agree that strangulation should be included in the differential diagnosis of any patient, particularly younger women, presenting with dysphagia or hoarseness.
This is also a timely reminder that family physicians should routinely screen all women of reproductive age for IPV.1 Although open-ended questions are the best way to begin a trusting dialogue,2 we also agree with Drs. Giusti and Ravi that more directly focused questions are necessary when evaluating patients with new symptoms and with chronic, unexplained functional distress or pain.