HSC Section 6 Nov2016 Green Book

Miles et al

etiology patients. Sensitivity of the screen was 63% with 100% specificity. Sensitivity increased to 71% with the inclu- sion of a barium capsule. In comparison to the esophagram, the esophageal screen subjects patients to approximately 10 times less radiation dose and is relatively quickly completed at the end of a standard VFSS procedure. 11 The aim of this pro- spective, observational study was to investigate the prevalence of esophageal abnormalities in an SLP-led VFSS clinic. Methods This study received appropriate regional ethics approval (University of Auckland Human Participants Ethics Committee 9263). Participants Data from 111 inpatients and outpatients consecutively referred to an SLP-led VFSS clinic (between May and December 2013) were collected. Patients were referred by the ORL service (59) or by another speech-language pathol- ogist (52), with a mean (SD) cohort age of 71 (14.95) years (range, 20-95 years). Fifty-one patients were male (46%). Referrals were all for complaints of dysphagia attributed to mixed etiologies: 36 neurological (32%), 37 dysphagia of unknown cause (33%), 28 otorhinolaryngology (eg, head and neck cancer [25%]), and 10 other (eg, unwell elderly [9%]). Participants were excluded if their VFSS recording had no esophageal visualization or had no timer or no cali- bration ring, since these were required to complete the timing and displacement measures. Esophageal Videofluoroscopic Assessment Studies were performed in a radiology suite using a Videofluoroscope (Toshiba, Tokyo, Japan) and recorded at 30 frames per second onto a USB drive. Timing information was superimposed on the fluoroscopic recording in 100ths of a second using a Horita VS-50 Video Stopwatch (Horita, Capistrano Beach, California). A 19-mm diameter radio- opaque ring was taped to the patient’s chin (in the lateral plane) and shoulder (in the anterior-posterior plane) to allow calibration for displacement measures. A medical radiation technician (MRT) and a speech-language pathologist were present at all procedures. For the standard VFSS protocol, the patient was screened in the lateral plane. The patient was presented with 1 mL, 3 mL, and then 20 mL of thin barium (E-Z Paque, E-Z-EM Anjou, Canada; 100% w/v) followed by half a cup of thin barium through a straw. The patient was then given 3 mL of barium paste (E-Z paste, E-Z-EM; 60% w/w). The procedure was truncated if required for patient safety. The esophageal phase involved the introduction of 2 boluses after completion of the standard VFSS protocol: a 20-mL fluid bolus and a 13-mm barium capsule. The patient was positioned in the anterior-posterior plane, standing whenever possible. The patient was asked to ‘‘swallow all in one go’’ to avoid deglutitive inhibition. The MRT fol- lowed the bolus from the oral cavity through the lower

esophageal sphincter (LES) until clearance into the stomach. Screening was continued for up to 15 seconds. If there was still residue in the esophagus, screening was ceased for 15 seconds, then recommenced. If residue was still present, the patient was asked to take a dry swallow to see if clearance occurred. If residue was still present, the patient was then offered a water swallow as well as being asked if he or she could feel any remaining bolus. A screen shot was used to identify complete clearance. Data Collected Age, sex, and comorbidities were recorded for each patient. Each VFSS was analyzed using real-time and frame-by-frame viewing (Quicktime Media Player; Apple, Cupertino, California). Videos were scored for the presence of oral, phar- yngeal, and esophageal abnormalities (yes/ no). Prolonged bolus manipulation, anterior spillage from lips, premature spil- lage into the pharynx, and oral residue were all considered oral abnormalities. Nasal regurgitation, reduced epiglottic deflection, delay in swallowing initiation, pharyngeal residue, penetration, aspiration, and prolonged pharyngeal transit time were considered pharyngeal abnormalities. Esophageal bolus stasis, bolus redirection/intraesophageal reflux, gastroesopha- geal reflux, esophagopharyngeal reflux, hiatal hernia, pro- longed esophageal transit, and pill stasis were all considered esophageal abnormalities. Pharyngeal transit time (PTT) was recorded and translated into a binary measure of (1) within normal limits vs (2) more than 2 standard deviations (SD) out- side of normal limits. 12 Esophageal transit time (ETT) was also recorded. A conservative cutoff of over 15 seconds was selected for abnormality. Previous published work has defined normal liquid transit through the esophagus as less than 13 seconds. 11,13,14 Maximum penetration-aspiration scale (PAS) scores were recorded, and scores 6 and above were considered an aspiration event. 15 To explore whether esophageal abnorm- alities can be predicted by objective pharyngeal measures, we calculated the pharyngeal constriction ratio (PCR) 12 and phar- yngoesophageal segment maximum opening (PESmax) 12 using the Universal Desktop Ruler (AVPSoft). These measures were also translated into binary measures of (1) within normal limits vs (2) more than 2 SD outside of normal limits. 12 All measures were taken from the largest fluid bolus ingested. Data Analysis Swallow studies were reported by an experienced otolaryn- gologist, specializing in dysphagia management, and by a speech-language pathologist, trained in quantitative analysis of VFSS using the method developed by Leonard and Kendall. 12 Interrater reliability for all measures was calcu- lated on 30% of videos by a third researcher. Videos were randomly selected by a fourth researcher. The third rater was blinded to the first researcher’s scoring and patient etiology. Total agreement across measures was 98%, with a k coefficient of 0.92. Lack of agreement was found for 1 PAS score (1 vs 2), and although there was slight variance in PESmax (maximum variance .08) and PCR (maximum variance .07), this did not change binary measures of within

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