When "Sarcopenic Dysphagia" Is Not the Answer

An older woman in her late 70s was referred for swallowing assessment because of recurrent aspiration pneumonia, weight loss, low body mass index, reduced handgrip strength, and slow gait speed, initially suggesting sarcopenic dysphagia. However, flexible endoscopic evaluation of swallowing and videofluoroscopic swallowing study demonstrated marked delay in swallow initiation, impaired airway protective reflexes, and reduced pharyngeal sensation despite the absence of substantial pharyngeal residue and relatively preserved upper esophageal sphincter opening. Careful reassessment of the videofluoroscopic study revealed abnormal craniovertebral alignment. Subsequent computed tomography demonstrated atlantoaxial dislocation with superior migration of the odontoid process, and magnetic resonance imaging confirmed compression of the medulla oblongata. This case highlights the importance of avoiding oversimplified attribution of dysphagia to sarcopenia and of reconsidering alternative neural or structural mechanisms when observed swallowing physiology is discordant with the presumed diagnosis.