Co-authors: Kendrea L. (Focht) Garand, PhD, CScD, CCC-SLP, BCS-S; Rachel Scheidler, M.S. CCC-SLP, CBIS

Introduction

Throughout June, we celebrated National Dysphagia Awareness month in the United States. Since 2008, clinicians, scientists and patients alike have taken time in June to spread awareness of dysphagia, a life-altering symptom of disease or ailment. Many of the clinicians and/or researchers reading this post have likely dedicated their lives to helping individuals with difficulty swallowing. This career choice is incredibly rewarding yet challenging. Various professionals, from basic scientists to clinical providers, work tirelessly to improve understanding of dysphagia and its impact to optimize patient care. This is done with the unified goal of ensuring that people can safely and efficiently participate in some of the most basic (and very social!) human behaviors: eating and drinking. 

In many ways, dysphagia care is uncharted medical territory. There are numerous frontiers to explore in the areas of diagnostics and treatments in dysphagia. One area of uncultivated practice relates to multiphase dysphagia – or the simultaneous presence of swallowing impairment across multiple swallowing “phases” or “stages”. 

Traditionally, swallowing has been arbitrarily categorized into three phases: oral, pharyngeal and esophageal. When we assess swallowing function, practitioners often further dichotomize these phases into oropharyngeal and esophageal stages, and an unfortunate result is the separation of these two “phases” during our assessment procedures. For example, despite evidence supporting the influences of impairment of one phase impacting another, complete assessment of the entire mechanism (mouth to stomach) is not routinely practiced during the modified barium swallow study (MBSS). Therefore, there is an important call for professionals across practice specialties and from bench to bedside to consider the interconnectivity of swallowing “phases” and the impact on dysphagia practice, including our assessment procedures.

An important question arose during dysphagia awareness month, are we (clinicians) aware of the impact of multiphase dysphagia in clinical practice and how does this impact our role in providing dysphagia services?

We turned to four esteemed colleagues representing four healthcare disciplines frequently involved in dysphagia care: 1) Dr. Joel Richter is a Gastroenterologist and Esophagologist (GI), 2) Dr. Ashli O’Rourke is an Otolaryngologist or Ear Nose and Throat (ENT) Surgeon, 3) Dr. Anna Miles is a Speech-Language Pathologist (SLP), and 4) Dr. Cheri Canon is a Radiologist (RAD). We wish to share this interdisciplinary perspective on multiphase dysphagia care in clinical practice, specifically regarding the clinical utility of esophageal visualization during the MBSS.

Questions and Answers

1. Do you support the use of esophageal visualization during the modified barium swallow study and why or why not?

GI:  This is a “no brainer” for an esophagologist. We certainly know that a good history may not accurately locate the site of dysphagia in 25% to 40% of patients. All should agree that barium studies are a simple and relatively inexpensive method to evaluate the esophagus giving good detail on motility (bolus passage) and anatomic issues.

Furthermore esophageal causes of dysphagia may impact oropharyngeal function and vice versa which may be important in treatment. Therefore, why stop at the CP area with your MBS when you have the patient and all the barium products to do a good general exam of the esophagus? For example, we recently reported in the journal Dysphagia our experience in 358 patients with oropharyngeal and cervical dysphagia (Watts, S.A., Gaziano, J., Jacobs, J., Richter, J., 2019). On the barium sweep 26% were found to have an esophageal abnormality –12% only had an esophageal abnormality which would have delayed diagnosis if not identified and 14% had both oropharyngeal and esophageal findings which if not identified together may have impaired appropriate treatment. (J. Richter, personal communication, June 25, 2020).

ENT: I do support the use of esophageal visualization during the videofluoroscopic evaluation of swallowing. I think it is important for clinicians to consider the swallowing mechanism from oral to gastric cavities and the impact that oropharyngeal dysfunction may have on esophageal function and vice versa. The bolus does not magically disappear after reaching the proximal esophagus and we should be curious about the “rest of the story.”  (A. O’Rourke, personal communication, July 17, 2020).

SLP: We have been using esophageal visualization within our modified barium swallow studies across New Zealand since 2014. This is not in exchange for a full esophagram (aka barium meal). It is a screen of esophageal clearance that provides crude information allowing timely referral for further esophageal investigation. Patients referred to radiology with likely esophageal dysphagia still receive an esophagram. 

Esophageal visualization in an upright position has established validity against the esophagram and manometry (Allen et al., 2012; Gullung et al., 2021). We have established normative timing values for a 20ml Level 0 – Thin bolus (Miles et al., 2016). MBSImP offers clinicians a simple measure of concern in their Component 17—Esophageal Clearance Upright Position. Reliability is also proven for assessing timing and stasis as well as making decisions about when to refer on to specialists for further management (Miles, 2016). (A. Miles, personal communication, June 19, 2020).

RAD: In recent years at UAB, we have changed our modified barium swallow protocol to include the “esophageal screen/scan” because literature supports its use. However, some of us anecdotally feel that it does not often add additional information for patient evaluation or therapy decisions. Regardless, lack of standardization of these types of swallows has been a historical deficit to their performance, patient evaluation, and importantly, research. Therefore, I feel it is important that we implement data-supported strategies in a consistent manner. (C. Canon, personal communication, June 24, 2020).

2. What are pros and cons of performing an esophageal screening during modified barium swallow study?

GI: As long as the patient can cooperate and does not have significant aspiration, I really see no down side. Advantages include:

1. One test to evaluate entire swallowing system from mouth to EG junction

2. Can be done by a combined SLP/radiology team or an appropriately trained SLP

3. High degree of accuracy (>85%) in defining important motility diseases (achalasia, scleroderma) or anatomic problems such as cervical webs, stricture, large hiatal hernia and even cancer

4. Minimal increase in radiation and no more than 5 minutes additional to MBS

(J. Richter, personal communication, June 25, 2020).

ENT: The pros to performing an esophageal screen is that it has been shown to have good correlation with positivity on dedicated esophageal diagnostic testing. I personally have been able to identify the occasional motility disorder such as hypercontractility or advanced achalasia as well as structural/anatomic defects such as distal esophageal stricture and hiatal hernia on esophageal screening. 

I think one of the cons to performing an esophageal screen is that there is not a well-defined protocol that is in use by a significant number of practitioners. Secondly, esophageal function can only be assessed in a cursory manner during a modified barium swallow. We must be sure that a negative screen is not the end of the diagnostic evaluation. The esophagram is a much more detailed examination and utilizes different contrast than we typically use for modified barium swallows. I don’t believe we know the real clinical significance, yet, of an upright screening examination of the esophagus. More correlation with esophageal diagnostic evaluations is needed (e.g. simultaneous esophageal HRM and screening videoflouroscopy). Also, I feel that we, as dysphagia clinicians, need to educate ourselves on the impact of things such as a double swallow and how this affects the primary peristaltic wave and therefore can impede esophageal bolus transit. (A. O’Rourke, personal communication, July 17, 2020).

SLP: The problem is that patients aren’t always able to tell their doctor whether their problems are esophageal or oropharyngeal. In fact ~60% of patients with hold up at the distal esophagus incorrectly locate their hold up at the sternal notch. And, many diseases and disorders had concurrent esophageal or oropharyngeal difficulties with >80% of people with Parkinson’s suffering from esophageal difficulties with or without oropharyngeal difficulties.

Our early work found that two thirds of patients with swallowing concerns referred for a modified barium swallow study had abnormal esophageal clearance on esophageal visualization (Miles et al., 2015). Yet, at the time, typically a modified barium swallow study visualized the oropharynx alone and did not view the esophagus. This 2015 study suggested that two thirds of patients would potentially have risk of incomplete diagnosis without an esophageal visualization. Those with solely esophageal swallowing difficulties would be sent home with no diagnosis and those with oropharyngeal and esophageal swallowing difficulties would potentially receive incomplete management. Using esophageal visualization allows timely referral for further investigation by appropriate medical specialties, avoiding incomplete management of patients with dysphagia. (A. Miles, personal communication, June 19, 2020).

RAD: The largest “pro” is the literature supporting its use and validating it as a screening procedure so that patients who may appear to have a normal oropharyngeal component of swallowing but a delayed esophageal transit will transition to additional studies such as manometry to hopefully identify an underlying cause of symptomatology. It is quick to perform; the additional radiation is (very) negligible. It does not add cost or significant time to the examination. There is no significant con as long as the radiologist and speech language pathologist team truly understands its utility. It is not an evaluation of esophageal motility itself, as that can only be accurately performed with a patient in a semi-prone position (thus removing the effects of gravity). (C. Canon, personal communication, June 24, 2020).

3. How does professional training or lack of, play a role in the dichotomization of oropharyngeal and esophageal swallowing assessment? Do you feel a speech pathologist can take a more active role in enhancing the modified barium swallow to include esophageal visualization?

GI:Even the radiology literature will support that a careful full barium esophagram is a “study of the past” in many medical centers. Training is poor with barium studies, a good study is time consuming with poor RVU reimbursement and increased radiation exposure while other tests like CT/MRI are easier to do and more lucrative. SLPs are uniquely qualified to extend their studies down through the entire esophagus needing no additional materials. In my experience at USF Swallowing Center, they can be easily taught to identify important impairment of bolus flow and anatomic abnormalities thereby giving direction for further tests (i.e. manometry or endoscopy) and possible treatments.

(J. Richter, personal communication, June 25, 2020).

ENT: I absolutely feel that speech-language pathologists, as dysphagia clinicians, are appropriate practitioners to be evaluating esophageal function. It is an area where the discipline can have significant impact and is right for patient care. The details, however, of how that manifests in clinical implementation has yet to be worked out. I do not, however, believe that an esophageal screen is the single best evaluation for esophageal dysphagia and function. Other studies, such as manometry or endoscopy may be necessary.  Therefore, I think focusing on this area alone would give some merit to criticisms regarding esophageal screening. If used correctly, I feel it is important. If it is the only evaluation, and the extent of the speech pathologist’s understanding of esophageal function, then it is inadequate. (A. O’Rourke, personal communication, July 17, 2020).

SLP: I think the key reason that esophageal visualization is not more established in SLP practice is that it has typically been the role of the radiologist, ear nose and throat surgeon or gastroenterologist to manage esophageal dysphagia. The SLP has typically focused on the oropharynx where more physical therapeutic interventions are possible. Esophageal dysphagia is treated with pharmaceutical and surgical interventions outside the scope of the SLP. However, the likelihood of SLPs coming into contact with patients with esophageal dysphagia incidentally is now well established. As SLPs we need to be skilled and able to “recognize … and assist in identifying primary or related esophageal phase problems” (ASHA, 2004). (A. Miles, personal communication, June 19, 2020).

RAD: The artificial delineation between the oropharyngeal phase of swallowing and the subsequent esophageal phase is just that. It is artificial. In part, it is likely due to variable training of radiologists vs. speech language pathologists. Unfortunately, modified barium swallowing training, and in general fluoroscopy training, is limited during diagnostic radiology residency and in fact, actually declining. The “lost art of fluoroscopy” is often bemoaned by me and like-minded colleagues. Additionally, many radiologists are not familiar with published literature in the speech language pathology/swallowing physiology realm. The radiology literature concerning swallowing is limited, and most of it is historical. I do think the speech language pathologists can take a more active role, not just in the discussion of the inclusion of esophageal emptying, but also to create a more codified multidisciplinary team with the radiologist. This can be challenging, but in institutions where this has been successfully cultivated, I am absolutely convinced that patients benefit, and there is increased fulfillment by the participants as they work together solving these complex swallowing pathophysiology conundrums. (C. Canon, personal communication, June 24, 2020).

4. What are barriers to implementing a more robust videofluoroscopic swallowing assessment to include esophageal visualization and how can they be addressed? 

GI: To a GI swallowing specialist like myself, there should be no barriers. This is in the best interest of the patient, more convenient and even insurance companies should like it. SLPs just need the training to do these studies alone or work more closely with radiologists in all patients with swallowing disorders rather than being segregated into separate “silos”. (J. Richter, personal communication, June 25, 2020).

ENT: As leaders in the field have pioneered the goal to standardize oropharyngeal videofluoroscopic swallowing assessments, I feel that it is time for us to standardize esophageal screening protocols used during modified barium swallows. This could be a place where a Delphi consensus or a special interest group of a society (ASHA Sig 13 or DRS) would be helpful. (A. O’Rourke, personal communication, July 17, 2020).

SLP: The most common barrier we’ve had is buy-in from our medical radiology technician (MRT) and radiologist colleagues. This change in SLP practice can only occur if the team is in agreement and working together. Esophageal visualization is a screen and therefore is only a triage to further investigations. Without buy-in from a medical practitioner to review studies of concern, the screen is not useful and the SLP is left with a recorded study without medical diagnostics and an action plan. We have always been able to successfully manage this barrier through multidisciplinary education and collaborative discussions. The evidence for the use of esophageal visualization is pretty convincing now and this has helped in multidisciplinary interactions.

It is the responsibility of educators to teach SLPs these skills, and not focus on the oropharynx alone. It is the responsibility of the individual SLP to build their knowledge and confidence in esophageal dysphagia in order to be an informed and skilled member of the multidisciplinary team in the management of dysphagia. (A. Miles, personal communication, June 19, 2020).

RAD: There are barriers to implementing a more robust video fluoroscopic swallowing assessment. First, the multidisciplinary team is a must and the individuals must engage not only during the fluoroscopic portion of the examination, but also in advance to discuss patient symptomatology and history, as well as after the study to discuss findings and planned strategies for treatment. If the radiologist engagement is limited to pressing her foot on the fluoroscopy pedal, no one benefits. Additionally, as part of the team, there should be a periodic review and discussion of the literature, perhaps in a journal club style. Additionally, monthly complicated esophageal swallowing conferences are an excellent tool to advance the practice and should include the speech language pathologist and radiologist, and also the gastroenterologist, esophagologist, and surgeons. Swallowing is one of the most complex physiologies in the body, and the clinical team should reflect this complexity. (C. Canon, personal communication, June 24, 2020).

Summary

Swallowing is a multiphase phenomenon. This not so simple process provides our bodies with nutrition and hydration. Beyond this however, eating and drinking is a social and enjoyable activity adding immeasurable quality of life. When there is something aberrant about the swallowing process, an accurate and timely diagnosis with subsequent treatment plan is critical. Given the known interconnectivity of the various “phases” of swallowing finding answers to explain patient symptoms and identifying appropriate interventions requires prompt assessment of the entire swallow continuum from mouth to stomach. Ultimately this requires interdisciplinary collaboration between several specialties such as GI, ENT, SLP, and radiology. There is a need for professional consensus for use of a standardized esophageal screening during the MBSS procedure. Implementing a quick and accurate esophageal screening allows for timely and appropriate referrals for gold standard assessment. Prompt, multidisciplinary input is crucial when considering dysphagia interventions. We must continue to raise awareness of dysphagia, including its multiphase impact in order to benefit our patient’s wellbeing and quality of life. 

Co-author Biographies

Dr. Garand is currently an Assistant Professor in the Department of Speech Pathology and Audiology in the College of Allied Health Professions at the University of South Alabama. She is the Founder and Director of the Swallowing Disorders Initiative Research Laboratory at the university. Her primary clinical and research interests include assessment and management of dysphagia in patients with neurodegenerative disease, specifically amyotrophic lateral sclerosis (ALS). Her previous publications include those featured in DysphagiaAmerican Journal of Speech-Language Pathology, and Annals of Otology, Rhinology and Rhinology. Funding support includes Veterans Affairs and the American Speech-Language-Hearing Foundation. 

Rachel Scheidler, M.S. CCC-SLP, CBIS holds a master’s degree in Communication Sciences and Disorders from Rush University, Chicago.  Currently she works in the hospital setting seeing patients within inpatient rehabilitation, outpatient clinic, and acute care units. Rachel has a strong interest in continuing education, especially in swallowing and swallowing disorders. She is a four-time ACE award recipient and holds numerous medical speech-language pathology certifications.

Contributing Colleagues

Dr. Joel Richter 

Joel E. Richter, MD, is currently Professor of Medicine and the Hugh F. Culverhouse Chair for Esophagology at the University of South Florida in Tampa. Joining the faculty in September 2011, he is also Director, Division of Digestive Diseases and Nutrition and Director, Joy McCann Culverhouse Center for Swallowing Disorders. He received his MD from the University of Texas Southwestern Medical School, Dallas. He completed his internship at the Naval Regional Medical Center, Philadelphia, Pennsylvania. He went on to complete his residency in medicine and fellowship in medicine (gastroenterology) at the National Naval Medical Center in Bethesda, Maryland. Among past academic appointments, Dr. Richter was chairman, Department of Gastroenterology, Cleveland Clinic Foundation, Ohio, for 10 years and Chairman of Medicine at Temple University School of Medicine, Philadelphia, PA for 7 years.

Dr. Richter is past president of the American College of Gastroenterology (ACG) and served as director, ACG, Institute for Clinical Research and Education from 1995 to 2004. He is the recipient of several awards for his work in digestive diseases, including the Berk/Fise Lifetime Clinical Achievement Award from ACG, Joseph B. Kirsner Award in Gastroenterology (2000), the Janssen Award in Gastroenterology for Clinical Research in Digestive Diseases (2001), and The Samuel Weiss Award for Outstanding Service to the ACG (2001). From 2002 to 2003, he served as president of the World Organization for Specialized Studies on Diseases of the Esophagus. He was co-editor in chief for the American Journal of Gastroenterology from 2003-2009. He was named to the Best Doctors in America for gastroenterology multiple times.

Dr. Richter is the author or coauthor of more than 325 original papers, 140 editorials/reviews, 15 books, and 116 book chapters. He and Don Castell are the editors of the new 5th Edition of The Esophagus. His research interests include gastroesophageal reflux disease, achalasia, Barrett’s esophagus, esophageal chest pain and eosinophilic esophagitis.

https://health.usf.edu/medicine/internalmedicine/swallowing/about-gi-team

Dr. Ashli O’Rourke 

Ashli O’Rourke, MD, MS, joined the MUSC Evelyn Trammell Institute for Voice & Swallowing in September 2012. Dr. O’Rourke began her professional career as a speech-language pathologist (SLP), earning her Master’s degree in Speech-Language Pathology and Audiology from Florida State University. After more than seven years of clinical speech therapy practice at Emory University Hospital, she attended medical school at the Medical College of Georgia. She completed her residency in Otolaryngology – Head and Neck Surgery at the University of Virginia in Charlottesville and her fellowship in Laryngology – Voice and Swallowing disorders at the Medical College of Georgia.

Dr. O’Rourke treats adult patients with problems located in the larynx (voice box), airway (wind pipe) and/or the esophagus (food pipe). This includes hoarseness or voice disturbances, dysphagia, or breathing difficulties due to airway narrowing or scarring. She is particularly interested in the diagnosis and treatment of swallowing disorders as well as laryngopharyngeal reflux disease. Her research interests include innovative technologies for the diagnosis and rehabilitation of swallowing disorders. Dr. O’Rourke sees outpatients in Mount Pleasant. She is board certified through the American Board of Otolaryngology.

https://muschealth.org/MUSCApps/ProviderDirectory/ORourke-Ashli

Dr. Anna Miles 

Anna Miles PhD is a full-time faculty memberin Speech Science, Psychology at The University of Auckland. Dr. Miles is a researcher, lecturer and clinician in the area of swallowing and swallowing disorders. She is the New Zealand Speech-language Therapists’ Association Clinical Expert in Adult Dysphagia. Anna is Principle Investigator of the Swallowing Research Laboratory in the Centre of Brain Research at The University of Auckland.

The Swallowing Research Laboratory at The University of Auckland, led by Dr. Miles, strives to improve the lives of people with swallowing difficulties throughimproved assessment, treatment and medical education. The laboratory hopes to reduce the risks of pneumonia and death associated with swallowing difficulties as well as improve the quality of life of suffers. 

In addition to research supervision, Anna provides clinical teaching to students at The University of Auckland and provides a considerable amount of international and national teaching each year. Anna is a specialist speech-language therapist in dysphagia and provides national teaching in specialty areas of endoscopic evaluation of swallowing, videofluoroscopic study of swallowing, surface EMG in dysphagia management and tracheostomy management.

https://unidirectory.auckland.ac.nz/profile/a-miles

Dr. Cheri Canon

Cheri L. Canon, MD, FACR, FAAWR, is a Professor and Witten-Stanley Endowed Chair of Radiology at the University of Alabama at Birmingham (UAB) Department of Radiology. She completed her undergraduate training at the University of Texas at Austin, followed by medical school at the University of Texas Medical Branch. After completing her residency training in diagnostic radiology at the University of Alabama at Birmingham, she joined the faculty in the abdominal imaging section. Dr. Canon served as the radiology residency program director and vice chair of education for seven years. She was the UAB School of Medicine Curriculum Committee chair when an organ-based curriculum was implemented. She then served as senior vice chair of operations and division director of diagnostic radiology before her appointment as chair. She sits on UAB Medicine Joint Operating Leadership Council, which is the senior leadership team for the health system. Dr. Canon served as an oral examiner for the American Board of Radiology (ABR) for eleven years, a member of the Board of Trustees, and now sits on its Board of Governors. She was the vice chair of the American College of Radiology (ACR), chancellor on the board, and previously served as the chair of the ACR Commission on Education. She is the President of the Society of Chairs of Academic Radiology Departments (SCARD) and the co-creator of LEAD, a new women’s leadership development program jointly developed by SCARD and GE Healthcare. Additionally, she sits on the boards of directors for the Association of University Radiologists, the Society of Abdominal Radiology, and the Academy of Radiology Research Academic Council. She is also active in the Birmingham community and is a member of the Birmingham Rotary Club. She is the president for MOMENTUM, a Birmingham women’s leadership organization.

https://providerdirectory.uabmedicine.org/provider/Cheri+Canon/572735

References

  1. Allen, J. E., White, C., Leonard, R., & Belafsky, P. C. (2011). Comparison of esophageal screen findings on videofluoroscopy with full esophagram results. Head & Neck, 34(2), 264–269. https://doi.org/10.1002/hed.21727
  2. Gullung, J. L., Hill, E. G., Castell, D. O., & Martin-Harris, B. (2012). Oropharyngeal and Esophageal Swallowing Impairments: Their Association and the Predictive Value of the Modified Barium Swallow Impairment Profile and Combined Multichannel Intraluminal Impedance—Esophageal Manometry. Annals of Otology, Rhinology & Laryngology, 121(11), 738–745. https://doi.org/10.1177/000348941212101107
  3. Martin-Harris, B., et al (2020). Best practices in Modified Barium Swallow Studies. American Journal of Speech-Language Pathology, 29, 1078-1093. https://doi.org/10.1044/2020_AJSLP-19-00189
  4. Martin-Harris, B., et al (2008). MBS measurement tool for swallow impairment—MBSImp: Establishing a standard. Dysphagia, 23(4):392-405. https://doi.org/10.1007/s00455-008-9185-9
  5. Miles, A. (2016). Inter-rater reliability for speech-language therapists’ judgement of oesophageal abnormality during oesophageal visualization. International Journal of Language & Communication Disorders, 52(4), 450–455. https://doi.org/10.1111/1460-6984.12283
  6. Miles, A., Clark, S., Jardine, M., & Allen, J. (2016). Esophageal Swallowing Timing Measures in Healthy Adults During Videofluoroscopy. Annals of Otology, Rhinology & Laryngology, 125(9), 764–769. https://doi.org/10.1177/0003489416653410
  7. Miles, A., Mcmillan, J., Ward, K., & Allen, J. (2015). Esophageal Visualization as an Adjunct to the Videofluoroscopic Study of Swallowing. Otolaryngology–Head and Neck Surgery, 152(3), 488–493. https://doi.org/10.1177/0194599814565599
  8. Watts, S., Gaziano, J., Jacobs, J., & Richter, J. (2019). Improving the diagnostic capability of the modified barium swallow study through standardization of an esophageal sweep protocol. Dysphagia34(1), 34-42.

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