Understanding the scope of esophageal disorders and the affect of such disorders on oropharyngeal function as well as having the knowledge and skills to recognize abnormalities in esophageal structure and function require additional training, knowledge and skills beyond the completion of traditional graduate coursework and practicum in swallowing and swallowing disorders. Most of the education in the area of esophageal disorders may be obtained from post graduate continuing education or if you are fortunate to be able to work closely with a gastroenterologist. Ideally study should include awareness of clinical symptoms of esophageal dysphagia and recognition of the presence of esophageal dysfunction from instrumental evaluations performed such as the esophagram.
The key to choosing the appropriate diagnostic exam: Patient medical history, clinical interview and clinical exam
The clinical examination includes noting pertinent signs and symptoms in the medical history associated with oropharyngeal and or esophageal dysphagia. Cook and colleagues indicated that a detailed history will elucidate the anatomical site and the likely cause of dysphagia in 80% of cases (1). Such signs and symptoms of possible esophageal dysphagia may include but are not limited to: food “sticking” during swallowing, difficulty swallowing solid food, sensation of discomfort or fullness anywhere from mid-chest to neck region, coughing up food/pills after the swallow, requiring liquid swallows to follow solids through the swallow, complaints of dysphagia without overt signs of swallowing difficulty, odynophagia (at base of throat/chest/sub-sternal), complaints of heartburn, chronic cough, throat clearing, excessive secretions or saliva, voice change, chronic sore throat, chronic respiratory problems, acidic taste or sinus problems, and regurgitation.
Based on medical history, clinical examination, and in the presence of symptoms of esophageal dysphagia as listed above or in the absence of oropharyngeal findings after completion of the instrumental examination, an esophagram is the appropriate first step in diagnosing esophageal disorders and should be requested.
Perhaps it is time for a multi-disciplinary group of deglutologists to define the purpose, methodology and value of the esophageal screen.
Many Speech Pathologists use the esophageal screen when the oropharyngeal swallow evaluation fails to yield findings that correlate with the patient’s symptoms. However there is no consistent protocol or rationale for completion of the esophageal screen. A screening protocol would dictate the rationale for: patient position, bolus viscosity and size administered, number of swallows performed by the patient per bolus to achieve the optimal representation of esophageal motor function and structural integrity. How do we interpret the findings from an esophageal screen? Do we perform the esophageal screen only in the absence of oropharyngeal dysphagia or is this screen done during every exam? Will the radiologist consent to assisting with an esophageal screen? Will the radiologist document the findings of an esophageal screen? If not, why not?
ASHA professional practice documents do not define the criterion or the elements of an esophageal screen (2). Additionally the American College of Radiology (ACR) Practice Guidelines for the Performance of the Modified Barium Swallows do not mention or define the esophageal screen for patients with dysphagia (3). Perhaps that is why we are not able to persuade the radiologist with whom we work to perform an esophageal screen or report the findings. The ACR guideline state that; “A complete patient evaluation may also include spot films of the pharynx for structural assessment and an esophagram, as symptoms of dysphagia are often poorly localized”. This guideline focuses on assessment of the pharynx but recommends performance of an esophagram if warranted (3). The guideline is an excellent reference supporting the inclusion of an esophagram in the absence of oropharyngeal findings and/or if the patient’s symptoms are suggestive of an esophageal origin for the swallowing disorder. Again, there is no mention in this document of an esophageal screen.
ACR Practice Guideline for the Performance of Esophagrams and Upper Gastrointestinal Examinations states; “the indications for performance of an esophagram include a pertinent history and symptoms. The symptoms include but are not limited to; chest pain without cardiac origin, symptomatic or suspected gastroesophageal reflux, dysphagia and odynophagia”. Further patient history indicators; “…motility disorders, esophagitis, strictures, varices, neoplasms, esophageal obstruction and postoperative assessment” (4).
The confirmatory radiographic procedure to evaluate esophageal motility and structure is the esophagram. The esophagram is performed in prone position so the esophageal motor function can be assessed without influence of gravity. Single, double barium contrast, gas producing effervescent crystals, and an optional marshmallow challenge are used during this evaluation. Large volumes of barium must be taken to evaluate the distension of the esophageal body. Double contrast barium is used to outline mucosal integrity and to optimize visualization of abnormalities. The patient must be able to consume quantities and varied types or densities of contrast for an accurate assessment of motor function and structure of the esophageal body and sphincteric function. Positive findings from the esophagram may result in further evaluation with endoscopy, manometry, impedance, combined impedance and pH testing, depending on the patient symptoms and findings from the esophagram.
Has the esophageal screen protocol been described?
Allen and colleagues (2012) described the esophageal screen as the administration of a single 20 ml liquid bolus swallowed and viewed in the anteroposterior view after completion of the oropharyngeal evaluation. The position of the patient was in upright, standing position with instructions that the patient swallow the bolus in one swallow. Esophageal screen findings were compared to the results of a full esophagram in the patients studied. They found the esophageal screen identified 44/70 (63%) patients with esophageal disease. Sensitivity and specificity were 63% and 100% respectively. The authors noted they may have had increased identification of esophagopharyngeal reflux and gastroesophgeal reflux with the esophageal screen. They also note that hiatal hernia and esophageal ring identification are best visualized with esophageal distention (use of large volumes of barium). Thus the sensitivity of the esophageal screen had limited identification of structural abnormalities such as hernias and rings because of the use of the 20 ml bolus. Conclusion of this study; “if clinical suspicion is high, a formal esophagram should be considered” (5). The conclusion supports the need to evaluate patients with esophageal disorders with the appropriate procedures and instrumentation.
Oropharyngeal Findings Associated with Esophageal Disorders
Blair and Martin-Harris (2010) found significant correlation between delayed pharyngeal swallow response time and abnormal esophageal clearance observed on an esophageal screen. The esophageal findings were confirmed by combined esophageal manometry and impedance (8).
In conclusion, do we as a profession have a consistent rationale, standardized methodology and predicted outcomes to support the performance of the esophageal screen? Perhaps it is time for a multi-disciplinary group of deglutologists to define the purpose, methodology and value of the esophageal screen.
Links of Interest
Dr. Easterling has two textbooks:
- “Principles of Deglutition: A Multidisciplinary Text for Swallowing and its Disorders” by Shaker, R., Belafsky P.C., Postma G.N, Easterling C. (Springer Pub. 2012)
- “Manual of Diagnostic and Therapeutic Techniques for Disorders of Deglutition” by Shaker R., Easterling C., Belafsky P.C., Postma G., (Springer Pub., 2012)
- Cook, I. J. (2008). Diagnostic evaluation of dysphagia. Nature Clinical Practice: Gastroenterology & Hepatology. 5,393-403.
- American Speech-Language-Hearing Association. (2004). Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies. Available: http://www.asha.org/policy retrieved 2-01-12.
- American College of Radiology (ACR) Practice Guideline for the performance of the Modified Barium Swallow (2011). Available: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/modified_barium_swallow.aspx retrieved 2-01-12.
- American College of Radiology (ACR) Practice Guideline for the performance of Esophagrams and Upper Gastrointestinal Examinations in Adults (2008). Available:http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/esophagrams_upper_gi.aspx retrieved 2-01-12.
- Allen, J.E. , White, C., Leonard R., & Belafsky P.C. (2012). Comparison of esophageal screen findings on videofluoroscopy with full esophagram results. Head & Neck. 34, 264-9.
- Blair, J., Martin-Harris, B. (2010, November). MBSImp and Combined MII/Esophageal Manometry. Paper presented at ASHA Annual Convention, Philadelphia.