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Reprinted by permission of Otolaryngol Head Neck Surg. 2015; 152(3):488-493.

Original Research—Laryngology and Neurolaryngology

Otolaryngology– Head and Neck Surgery

Esophageal Visualization as an Adjunct to the Videofluoroscopic Study of Swallowing

2015, Vol. 152(3) 488–493 ! American Academy of Otolaryngology—Head and Neck

Surgery Foundation 2015 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814565599 http://otojournal.org

Anna Miles, PhD 1 , Jessica McMillan, MSc 1 , Katie Ward, MSc 2 , and Jacqui Allen, MBChB, FRACS 1,2

Received August 13, 2014; revised October 23, 2014; accepted December 4, 2014. A ssociations between oropharyngeal abnormalities and esophageal abnormalities are poorly understood but well documented. 1-3 Oropharyngeal alterations have been reported in patients with gastroesophageal reflux disease. 4 Neurologic diseases such as Parkinson disease 5,6 and systemic conditions such as scleroderma 7 lead to both oropharyngeal and esophageal abnormalities. In a recent study using high-resolution manometry, O’Rourke and col- leagues 8 describe a variety of esophageal alterations during voluntary pharyngeal maneuvers (effortful swallow and Mendelsohn), adding to the theory that changing one point in the swallowing system can lead to positive or negative changes elsewhere. In addition, patient accuracy in locating the level of bolus holdup has been shown to be poor, with patients often indicating the cervical region or levels more proximal than the true site of bolus stasis, particularly when this occurs in the esophagus. 1,9,10 Smith and colleagues 10 reported 57% of respondents located a solid bolus impacted at a distal esophageal ring to the level of the sternal notch. Complaints of dysphagia for solids regularly lead to speech-language pathology (SLP) referral rather than gastroen- terology or otorhinolaryngology (ORL). Traditionally, SLP-led videofluoroscopic study of swallowing (VFSS) has assessed the oropharynx exclusively, even when symptoms might sug- gest esophageal complaints. This results in failure to identify patients with esophageal problems. These patients are sent home with no diagnosis and either continue to manage their symptoms alone or undergo a variety of other diagnostic tests over a prolonged period of time before reaching correct diag- nosis and treatment. An esophageal screen was described and validated by Allen and colleagues in 2012. 11 They compared fluid esophageal screens with full esophagrams in 74 mixed-

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective . Complaints of dysphagia for solids lead to speech- language pathology (SLP) referral. Yet many of these patients are later diagnosed with esophageal rather than oropharyn- geal dysphagia. Fluoroscopic screening involving the oro- pharynx alone fails to identify these patients. The aim of this study was to investigate the prevalence of esophageal abnormalities in an SLP-led videofluoroscopic study of swal- lowing (VFSS) clinic. Subjects and Methods . In total, 111 consecutive mixed- etiology patients referred to the clinic by otorhinolaryngol- ogy (ORL) (59) or by a speech-language pathologist (52) were recruited. A VFSS was performed according to proto- col, and at completion, esophageal visualization (in anterior- posterior plane) was performed by administration of a large liquid barium bolus and a barium capsule. All VFSS record- ings were analyzed using objective digital measures of timing and displacement. Results . Sixty-eight percent of patients had an abnormal eso- phageal transit. One-third of those referred presented exclusively with esophageal abnormalities, while one-third had both oropharyngeal and esophageal abnormalities. Oral abnormalities, reduced pharyngoesophageal segment maxi- mum opening (PESmax), and increasing age were significantly associated with esophageal abnormalities. Conclusion . Fluoroscopic evaluation of the pharynx alone, without esophageal review, risks incomplete diagnosis of patients with esophageal disorders. Using esophageal visuali- zation allows timely referral for further investigation by appropriate medical specialties, avoiding incomplete manage- ment of patients with dysphagia. Study Design . Prospective, observational study. Setting . Radiology suite, public hospital.

1 The University of Auckland, Auckland, New Zealand 2 Waitemata District Health Board, Auckland, New Zealand

Corresponding Author: Anna Miles, PhD, Speech Science, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. Email: a.miles@auckland.ac.nz

Keywords deglutition, deglutition disorders, dysphagia, esophageal visua- lization, speech-language pathology, otorhinolaryngology

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